HomeMy WebLinkAboutGoldsmith (2) OFFI-CE OF THE TOWN CLERKFD -
Town of Southold , oO�vF _ CSG
Judith T. Terry, Town Clerk
Town Hall,- 53095 Main Road i -
P. O. Box 1179
Southold, -New York 11971 0 ,aOP;
Telephone -0[ t
(5.16) 765-1801
•
- TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No. 404 Residential x
Non-Residential
- Fee $ 10.00
Septic Cesspool_x__
NAME OF OWNER: A. GoldsmithF.
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OWNER MAILING ADDRESS: 2420 Hobart Rpad '•
Southold, New York 11971
OWNER PROPERTY ADDRESS: 2420 Hobart-Road a;
Southold, New York
- OWNER TELEPHONE NUMBER: 516-765-3429
TAX MAP NO. : Section 64 Block 3 Lot 8
CROSS STREET: Old Shipyard Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New ExistingX
Residential , X Non-Residential
DATE OF PREVIOUS PUMP-OUT: March 30, 1987
Judith T. Terry
Southold Town Clerk
DATE: August 19, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold �� CQ ':, Application No. 4716 V
Judith T. Terry, Town Clerk
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Town Hall, 53095 Main Road Residential
P. O. Box 1179 �' ' • Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. %bc(
Fee $ /6.
DATE �`si
OWNER NAME: v &0\\- \\(0,4:-\\\,,N,
OWNER MAILING ADDRESS: oZ�,a,D ��,s-\—
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OWNER PROPERTY ADDRESS: SW/11 6
OWNER TELEPHONE NUMBER: �I (pc„
TAX MAP NO. : Section 4 Block Lot 7
CROSS STREET: C B��J ,� ` ,QQ/,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential t7 Noxi-Residential
DATE OF PREVIOUS PUMP-OUT: S3^v 4a't
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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igna' re of .nt
RECEIVED BY:
Town Clerk's Office ,
DATE:
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