HomeMy WebLinkAboutFarley OFFICE OF THE TOWN CLERK ' •c31F(U
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Town of Southold �� CDG
Judith T. Terry, Town Clerk `-
Town Hall, 53095 Main Road c u
P. O. Box 1179 r
Southold, New York 11971 4 [' ��•1,,
Telephone _ O! * �� �' •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 57 Residential XX
Non-Residential
Fee $ 10.00
Septic- Cesspool XX
NAME OF OWNER: Thomas P. Farley
OWNER MAILING ADDRESS: 7800 Peconic Bay Blvd. , Box 182
Mattituck, New York 11952
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OWNER -PROP-ERTY-ADDRESS: --7800--Peconic-,Bay.-BIvd..
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-4266 -
TAX MAP NO. : Section 126 Block 11 Lot 15
CROSS STREET: Bray Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XX New Existing XX
Residential XX Non-Residential
DATE OF PREVIOUS PUMP-OUT: August 1986
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Judith T. Terry
Southold Town Clerk
DATE: September 22, 1986
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C0FOC,r��=
Town of Southold % ;_ - CQ Application No. ��
Judith T. Terry, Town Clerk . `
Town Hall, 53095 Main Road Y`' ...c% Residential /'
P. O. Box 1179 �� ', ,4f *VA , Non-Residential
Southold, New York 11971 0 ® _1
_ off..
Telephone ®1 ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. `fl
Fee $ /. ` / / /
7://9; j7/,e7
DATE /
OWNER NAME: ` / /-40//,ri / • / } ,ASL ��
OWNER MAILING ADDRESS:7,for? 4-,-"e6,/v/eZ: y ei..C.--,.
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OWNER PROPERTY ADDRESS: ,--C--,,f4 /)j f
OWNER TELEPHONE NUMBER: er/ --, - J. 9f- 4/.4-- Z--
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TAX MAP NO. : Section 6 -Cr7Block .%/ Lot-,/,..r
CROSS STREET: trr l/k't ')� egfia(f,_de... .. ,eN:9 peeed L
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool J,/ New Existing - t--'---
Residential 1-`� ,Non-Residential
DATE OF PREVIOUS PUMP-OUT: ✓e/
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.)
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Signature of A icant
RECEIVED BY: c ed d{,-r t._.J
Town//Clerk's Office
DATE: i t, , oio? , /5/6
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