HomeMy WebLinkAboutMason 1`
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r 4 Town Hall, 53095 Main Road
%® O `' P.O. Box 1179
®��� Southold, New York 11971
JUDITH T.TERRY „ i�iij 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. 1247-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MASON, CATHERINE M.
Mailing Address 1 RR1 BOX 345 HOLDEN AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1
Property Address 2
City St Zip 00000-0000
Owner Telephone No. 516-734-6563
Tax Map No. section 110.00 block 2 lot 13.000
Cross Street DICK'S POINT
Date Of Last Pump Out 0/00/00
Issue Date: 9/22/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFILE OF THE TOWN CLERK o / r�
Town of Southold 5�� �`�
�� CQ ' Application No.),a(13
Judith T. Terry, Town Clerk • F i $10.00 - Residential
Town Hall, 53095 Main Road ` -''fk
P. 0. Box 1179 Ls, ;x. '' ;:4:4z $25.00 - Non-Residential
Southold, New York 11971 p '' �'' `� •'
Telephone O•(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
74 /f
OWNER NAME: (U C • •
OWNER MAILING ADDRESS: l•e a £L.'' 1-4 LUL--,
i1'1 - rr- rruc/< Ii9r -
OWNER PROPERTY ADDRESS: 54 1 F^
OWNER TELEPHONE NUMBER: !1 VE 19
TAX MAP NO. : Section /6 Block 1-1 Lot
CROSS STREET: fl(cxJfY\ e
l _
TYPE OF SYSTEM: Septic Tank / New Existing
�/
Cesspool '`-r 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.)
Orf
Signa re of Applicant
RECEIVED BY: _ / L I J
l' I L�
own Clerk's Off ce
DATE: �— . - '
7