HomeMy WebLinkAboutFliss OFFICE OF THE TOWN CLERK .4WOU(`,O
Town of Southold `
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Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road "mac
P. 0. Box 1179 ,,s‘r2
Southold, New York 11971 O -1�`c-
Telephone *t
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 279 Residential
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Anna Fliss
OWNER MAILING ADDRESS: RR 1 , Box 27 Bray Avenue
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: RR1 , Box 27 Bray Avenue
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-4107
TAX MAP NO. : Section 126 Block 2 Lot 6
CROSS STREET: Main Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: December 12. 1986
Judith T. Terr
Southold Town C erk
DATE: April 22,' 1987,
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �UFFQ/I
Town of Southold ��`� eQ Application No.c>2 9
Judith T. Terry, Town Clerk •
Town Hall, 53095 Main Road a ,� s‘.( 7 Residential
P. O. Box 1179 u' : ° Non-Residential
Southold, New York 11971 4 $
Telephone
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
J
DATE lam' .c,� / G ' g /
OWNER NAME: Anna Fliss
OWNER MAILING ADDRESS: RR1 Box 27 Bray Ave. r i. . _ .: . , id.
Mattituck, N.Y. 11952
OWNER PROPERTY ADDRESS: Same
OWNER TELEPHONE NUMBER: 516-298-4107
TAX MAP NO. : Section 126 Block 2 Lot 6
CROSS STREET: Main Rd.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Dec. 12, 1987
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.)
Signature of Applicant
RECEIVED BY:
Town CI rk's Of ce
RECEUVED
DATE:
APR 1G 1987
Town Clerk Southold
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