HomeMy WebLinkAboutMalone (3) JUDITH T. TERRY ' A Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ®� Fax (516) 765-1823
N. �® ��®��! Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1858-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MALONE, WALTER
Mailing Address 1 55 CALVERT AVENUE
Mailing Address 2
City St Zip COMMACK NY 11725-0000
Property Address 1 3250 CEDAR BEACH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-499-0277
Tax Map No. section 91 .00 block 1 lot 15.000
Cross Street SUNRISE WAY
Date Of Last Pump Out 0/00/00
Issue Date: 3/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE rOF THE TOWN CLERK •0 FOU(
Town of Southold � CQ - Application No. /F-S r
Judith T. Terry, Town Clerk .
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Town Hall, 53095 Main Road $10.00 - Residential
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P. O. Box 1179 ��- z $25.00 - Non-Residential
Southold, New York 11971 O
Telephone ‘N •
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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 $
DATE v\-41,
OWNER NAME: %/42./17Z--'
OWNER MAILING ADDRESS: -c eviar Alf
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OWNER PROPERTY ADDRESS: �� Ced/a.
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OWNER TELEPHONE NUMBER: \f /' V99z 7- 7 7
TAX MAP NO. : Section ) Block ) Lot
-CROSS STREET: 4J ,e(Te 0,gy
TYPE OF SYSTEM: - Septic Tank - - New Existing
Cesspool LV New Existing e�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: —` // r c-e_ae-- -
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:
LUif
own Clerk's Office
DATE: 5 (�_ -
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