HomeMy WebLinkAboutMasters JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ,• b: ) P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �j \' c Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER •_.>� y R o y
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_•�' ., 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. 1596-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner , MASTERS, MARNA N.
Mailing Address 1 P. O. BOX 324
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 8175 PECONIC BAY BOULEVARD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8470
Tax Map No. section 126.00 block 9 lot 25.000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 1/17/91 Judith T. Terr
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK WFOUre,
Town of Southold �S ��D = Application No. /St
Judith T. Terry, Town Clerkf :y
Town Hall, 53095 Main Road , $10.00 - Residential Ta—rj
P. O. Box 1179 ``` `;
tri $25.00 - Non-Residential
Southold, New York 11971 O �, �J
Telephone ®j NtO "��
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /
Fee $ /°+-"flPi
DATE 11.2 /f/f 6
OWNER NAME: arn/d Ai/1164;6 r6 (Ma EroP, )
OWNER MAILING ADDRESS: fp
,, !d ,,,„k 1 / 1 475
1 ,
OWNER PROPERTY ADDRESS: el � /� �'31�� 8 ent (y
OWNER TELEPHONE NUMBER: f' 7O
TAX MAP NO. : Section / p --- Block I Lot e
CROSS STREET: 6 11',4 698 4p�• ,f g) gray Ave., ( t4(,)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 4, New Existing A_
Residential A Non-Residential
DATE OFV4O-U-S• PUMP-OUT: IV/e/9 o
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: