HomeMy WebLinkAboutLindsay ,ii\VIiLkC%
• Town Hall, 53095 Main Road
k�®� - ` ' `�®� ;'� P.O. Box 1179
Ls. Southold, New York 11971
JUDITH T.TERRY =� .F�,0/1,0FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1450-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LINDSAY, AGNES
Mailing Address 1 BOX 605
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 BUNGALOW LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4090
Tax Map No. section 123.00 block 3 lot 15.000
Cross Street CENTER STREET
Date Of Last Pump Out 0/00/00
Issue Date: 5/07/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK -4FFUUr�'-
Town of Southold Q C�G_ Application No. / 4/�-y'
Judith T. Terry, Town Clerk 'S; „r -,
Town Hall, 53095 Main Road
$10.00 - Residential v
p. 0. Box 1179 - CJ' � ,
*` t ' ? z $25.00 - Non-Residential
Southold, New York 11971 O ;® ��`�
Telephone 1 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD'WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE v,i,gd
•
OWNER NAME: # ; - % •
•
OWNER MAILING ADDRESS: A (CO
OWNER PROPERTY ADDRESS: u j,\ cx hU Cu Ia NQ
OWNER TELEPHONE NUMBER: —2 9fr qo 9
TAX MAP NO. : Section ' Z3 y Block Lot /3
CROSS STREET: CilAtiCV (41,,,L1)-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
/
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
0
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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Signatur- of Appl*/ ant
RECEIVED BY: " A
/ Town Clerk's Office
DATE: lJ // /'4
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