HomeMy WebLinkAboutMack roll 4P1_, t;_
Town Hall, 53095 Main Road
P.O. Box 1179
= �, - �`� ' Southold, New York 11971
JUDITH T.TERRY • 1• TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR 01-VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK, or CESSPOOL
Operation Permit No. 843-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MACK, ARTHUR AND TESSIE
Mailing Address 1 1475 SHIPS DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1475 SHIPS DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-9247
Tax Map No. section 79. 00 block 3 lot 38.000
Cross Street NORTH BAYVIEW ROAD
Date Of Last Pump Out 5/00/85
Issue Date: 9/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK FO(A,
Town of Southold Application No. r
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a ,' -� I Residential �---
P. O. Box 1179 r �?u" ; _ i
syr- 4,}';;-r Non-Residential
Southold, New York 11971 O ®, `:c" �f
19 �. oma,,
Telephone Q( .„. `A�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
. DATE a/1 ” S g-
• OWNER NAME: 4 (zz—Esc Cf�
OWNER MAILING ADDRESS: P.17 7 S 14 r fo S' Vel,
OWNER PROPERTY ADDRESS: Jt
OWNER TELEPHONE NUMBER: r i G - 76 S % 2 y 7
TAX MAP NO. : Section Block3 Lot14#- s3e
CROSS STREET: N, fel 7 i
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /1, 471 1 1g
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 Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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