HomeMy WebLinkAboutOsprey Dominion I��ei OFOL,' ,
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JUDITH T.TERRY ����� Town Hall, 53095 Main Road
TOWN CLERK ; ti = P.O. Box 1179
v1,7 ,1 Southold, New York 11971
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REGISTRAR OF VITAL STATISTICS O
MARRIAGE OFFICERy� 0' #1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER : 491 * �► ,�ii Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 157-N Residential Non-Residential X
Fee $ 25.00 New X Existing
Name Of Owner OSPREY DOMINION CO.
Mailing Address 1 71 CAROLYN BLVD.
Mailing Address 2
City St Zip FARMINGDALE NY 11735-0000
Property Address 1 44075 MAIN ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-6188
Tax Map No. section 75.00 block 1 lot 20.000
Cross Street PECONIC LANE
Issue Date: 6/14/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
s e I •' %
OFFICE C.F THE TOWN CLERK
Town of Southold , st' s FF�(/(' ,QG Application No( Li -7
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Judith T. Terry, Town Clerk . y
Town Hall, 53095 Main Road - $10.00 - Residential
P. O. Box 1179 ;' $25.00 - Non-Residential
Southold, New York 11971 -410./
Ories
Telephone 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ �5
DATE (4\c'-'t Z • \C,`'i4
OWNER NAME: 0S7red .vc".^•oma Co,
OWNER MAILING ADDRESS:1\ evo\T -t1A•_
ccemn&c\4z-i \\"? 3S
OWNER PROPERTY ADDRESS: IVA01'S AC A
Wtacr•C, , N •tW,S€
OWNER TELEPHONE NUMBER: 165-6\16$
TAX MAP NO. : Section 1 5 Block I Lot -Z-°
• ; CROSS STREET: '?e..contc. l-c^Q; - •
TYPE-.OF ,SYSTEM: Septic Tank-- _' • New /( Existing Or
Cesspool New )" Existing
Residential Non-Residential X
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.)
i . A
Signature of Applica t
•
RECEIVED BY,: ,
Town• Clerk's Office
DATE: