HomeMy WebLinkAboutSouthold United Methodist •
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JUDITH T. TERRY L Town Hall, 53095 Main Road
TOWN CLERK t ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS • J Southold, New York 11971
MARRIAGE OFFICER ® Fax (516) 765-1823
Ak , 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. 143-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner SOUTHOLD UNITED METHODIST
Mailing Address 1 CHURCH
Mailing Address 2 P. O. BOX 62 _
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 53930 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3449
Tax Map No. section 61 .00 block 4 lot 19.001
Cross Street MECHANIC 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 oS0FO(4 -A)
Town of Southold �� _,_•, - CQG' Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road c I $10.00 - Residential ��
p. O. Box 1179 �' V- 1n< i • $25.00 - Non-Residential
Southold, New York 11971 O ® {' �•`�
Telephone 0.(A'3n 101
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
• Fee $
DATE / P- :CAA/ //3
•
OWNER NAME: Southold Un;md Methodist Church
P.O.Box 62 Main Rd.
OWNER MAILING ADDRESS: ,Southold,NY 11971
OWNER PROPERTY ADDRESS:
3Ss
.Soa,tjtU'd Un'�d�dathralict,L'Izur�h " D
PO.Box 62 Main Rd.
Southold,NY 11971
OWNER TELEPHONE NUMBER: 5-14
TAX MAP NO. : Section co Block Li Lot f �'
CROSS STREET: r1CI•'rv,' 1-c
TYPE OF SYSTEM: Septic Tank ., +New�7 Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: .5g-v,r I G�t'r"
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.)
ignatu - . • pplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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