HomeMy WebLinkAboutLipp _ ` f
ivit 4 Town Hall, 53095 Main Road,
cam® P.O. Box 1179
-��®� s� ��! Southold, New York 11971
JUDITH T.TERRY ��"�� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1343-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LIPP, RONALD J.
Mailing Address 1 P. O. BOX 1003
Mailing Address 2
City St Zip SOUTHOLD NY 11971-000Q
Property Address 1 2300 PARADISE SHORES ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1278
Tax Map No. section 80.00 block 1 lot 11 .000
Cross Street NORTH BAYVIEW ROAD
Date Of Last Pump Out 0/00/74
Issue Date: 12/18/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
. ... of
OFFICE OF THE TOWN CLERK cvFFO(k
Town of Southold Q BOG Application No. / Sc/
Judith T. Terry, Town Clerk ,
y
Town Hall, ' $10.00 - Residential
53095 Main Road .
cr3 _; ,mak,r�"
p. O. Box 1179 ujt ��_� � �i � $25.00 - Non-Residential
Southold, New York 11971 ®i "0 �
Telephone = ( `1%
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ,$/'//f rA
I ,
OWNER NAME: °R044/1-1,b
OWNER MAILING ADDRESS: ;'Z3o i',4c4 )1..fr-- S c 1 03
cm-0v //144w Y )l1-7I -
OWNER PROPERTY ADDRESS. � oz, e,„4'0j i o6o0-3
/ - J 674.•' Y
OWNER TELEPHONE NUMBER: 76-2, - i v -77
TAX MAP NO. : Section 0 Block / Lot
CROSS STREET: O M, 5 � � P o 111a°,;.} ?4WI 25141
TYPE OF SYSTEM: Septic Tank New Existing %-
Cesspool �// , New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Signature of Applican
RECEIVED BY:
Town Clerk's Office
RECEIVED
DATE:
DEC 1 '6
V w!n 1 erk Southold
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