HomeMy WebLinkAboutGraham ®�\\��
vs ,� Town Hall, 53095 Main Road
It.10 s c. P.O. Box 1179
AR/ � ��� Southold, New York 11971
JUDITH T.TERRY �� ,,4•0° 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. 637-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner GRAHAM EDWARD W.
Mailing Address 1 BOX 1083
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 ROGERS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3079
Tax Map No. section 66. 00 block 2 lot 42. 000
Cross Street HIPPODROME DRIVE
Date Of Last Pump Out 0/00/00
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Issue Date: 3/04/88 . Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c3VFFD(,(
Town of Southold �� Wit,. . CQ ' Application No. ,
Judith T. Terry, Town Clerk Residential
Town Hall, 53095 Main RoadLEq n:
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P. O. Box 1179 '': �W! ��' Non-Residential
Southold, New York 11971 O ®L' >0�1�`
Telephone *0 ' 0,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / p
DATE i / /Ui
OWNER NAME: / r/' . ..) Ifi l`.i1✓
OWNER MAILING ADDRESS: 4 ,/ 101.3
0-.(d 97,0,,,biyota, //cm
OWNER PROPERTY ADDRESS: / / , .
OWNER TELEPHONE NUMBER: 7f 5 4.30 7q
TAX MAP NO. : Section Ce Block Lot e"-/, .
CROSS STREET: /4 t p/a--0 13-a n E
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New / Existing 1
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: l i
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.) -
•
Signatur- of Applicant
0
RECEIVED BY: e.c; Q.J� �s,, �
Town ler Office
DATE: /V/Fr
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