HomeMy WebLinkAboutPierce Gam:
;` ojtjs Town Hall, 53095 Main Road
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P.O. Box 1179
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OFFICE OF THE TOWN CLERK
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Town of Southold . :. � '- Application No./Of
Judith T. Terry, Town Clerk '- 44.7i.. 4%
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Town Hall, 53095 Main Road s ` r -'� $10.00 - Residential
P. O. Box 1179 cr3141044 'moi $25.00 - Non-Residential
Southold, New York 11971 O ®
Telephone --"Qt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
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Fee $ ,S .
DATE Are. /P?°
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OWNER NAME: A//2y R "/2
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OWNER MAILING ADDRESS: B® 023S
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OWNER PROPERTY ADDRESS: /-75-,
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OWNER TELEPHONE NUMBER: 2‘.5- -`6y '
TAX MAP NO. : Section /1•1e Block / Lot /2.
CROSS STREET: MA ID
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /9e5--- (p )
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.)
SigVure of Applicant
RECEIVED BY: v ikcec,- / .
e _!lerk's 0 fice
DATE:
APR-2
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