HomeMy WebLinkAboutFleming 11 ,cv
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Town Hall, 53095 Main Road
N` .�� P.O. Box 1179
®� �Ela �►�� Southold, New York 11971
JUDITH T.TERRY
�', TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 647-R Residential X Non-Residential
Fee $ 10. 00 Septic X Cesspool
New X Existing
Name Of Owner FLEMING, DOUGLAS H.
Mailing Address 1 FLEMING, JOANNE ADAMS
Mailing Address 2 1445 EAST GILLETTE DRIVE
City St Zip EAST MARION NY 11939-0000
Property Address 1 825 LATHAM LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-477-0853
Tax Map No. section 15. 00 block 9 lot 1.240
Cross Street LAND' S END ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/08/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ocUWFD1r
Town of Southold - CQG Application No. (7 /
Judith T. Terry, Town Clerk /sir
Town Hall, 53095 Main Road *!';64 : Residential
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i �� Non-Residential
P. O. Box 1179 � ; ��`
Southold, New York 11971 O "
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ `
DATE
OWNER NAME: ot.) lir-S. 11, �� LC VJY4��r'rr�� j� .a 'Ely"
OWNER MAILING ADDRESS: R , 2.4 v ( , L( vs EY STC-1 Il rr a o v`
ERI gr /1/11-nw-o:� 1(13 f
OWNER PROPERTY ADDRESS: V2---S nw �/�-�,e � L/Arki "-S' t:�J
l 6-ti-, fs1 1 . !1 i S -7
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OWNER TELEPHONE NUMBER: %--77 6153
TAX MAP NO. : Section Block f Lot i,2
CROSS STREET: �l��v�C f t1 Pree
TYPE OF SYSTEM: Septic Tank t/ New i/ Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
A-7c ,&/,/
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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