HomeMy WebLinkAboutMallgraf 14%44 4Ci.•
t Town Hall, 53095 Main Road
�® ��� P.O. Box 1179
Q( `a -�' Southold, New York 11971
JUDITH T.TERRY �,�"I,,
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OFFICE OF THE TOWN CLERK
Town of Southold �� CQ Application No. 7�
Judith T. Terry, Town Clerk . 0#�7Residential i►
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Town Hall, 53095 Main Road
P. O. Box 1179 cry = r '` i ; Non-Residential
Southold, New York 11971 O � •• z"$Telephone :o.( /P
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
• OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/0 q
DATE
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OWNER NAM• • / - l%i/l a ' tt- G!
d2ee-c-LeAi
OWNER MAILING • DDRESS: � el, V/
//9 7
OWNER PROPERTY ADDRESS: _, .
OWNER TELEPHONE NUMBER: 7j - /8 - 7�sc
TAX MAP NO. : Section 6/ Block r Lot 8
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto beforepermit maybe issued. U
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
/ � G�% / iii ►�
Signature of Applicant/ •
RECEIVED BY:4/1-ce
Town elerk's ffice
REM ►:
DATE:
MAY 2 51988
Town Clerk Southold •
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