HomeMy WebLinkAboutMann I,,/I//,iii
FFOLK
JUDITH T. TERRY �,. L : Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER yO° Fax (516) 765-1823
__ _ 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. 3088-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
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Name Of Owner MANN, RUSSELL E.
Mailing Address 1 P. O. BOX 1438
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1775 CALVES NECK ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2652
Tax Map No. section 70.00 block 4 lot 48.000
Cross Street
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c,VFFD(,r ` ��
Town of Southold Q �r CQG Application No. r
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Judith T. Terry, Town Clerk � � � �.N � � $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 u' _ tri `
� $25.00 - Non-Residential
Southold, New York 11971 ,�y� F*1-1!":::X ��`�
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Telephone = j Y1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: . .5.-.et-7 2- /27,00).d
OWNER MAILING ADDRESS: Po
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OWNER PROPERTY ADDRESS: /775- (J9- t/.25 ke,G4.)
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OWNER TELEPHONE NUMBER: ,,',r - 7/9 L�(� -,•
TAX MAP NO. : Section -7O Block
Lot r1
CROSS STREET: 44,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1/ 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 Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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