HomeMy WebLinkAboutGreen 14.647
JUDITH T. TERRY �; Town Hall, 53095 Main Road
TOWN CLERK ® rn P.O. Box 1179
REGISTRAR OF VITAL STATISTICS tf2 • Southold, New York 11971
MARRIAGE OFFICER �, ® 4 Fax (516) 765-1823
4ite 14.°46
� Telephone (516) 765-1801
1 41 001
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1765-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GREEN, ROSE
Mailing Address 1 P. O. BOX 207
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6741
Tax Map No. section 103.00 block 1 lot 6.000
Cross Street STILLWATER AVENUE
Date Of Last Pump Out 0/00/79
Issue Date: 9/23/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
`OFFICE OF THE TOWNCLERK c0FDUr
Town of Southold C
� �& Application No. X76 S�
Judith T. Terry, Town Clerk X0-4 $10.00 - Residential
Town Hall, 53095 Main Road
.G 1
P. O. Box 1179 tri ; ` � $25.00 - Non-Residential
Southold, New York 11971
Telephone - _0 '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O
DATE
OWNER NAME: os (^ F G
OWNER MAILING ADDRESS: T> a07
UTC o C--ti 7(9 3 s^
OWNER PROPERTY ADDRESS: /A( _N
OWNER TELEPHONE NUMBER: `7,3 C/- /, 7G7//
• TAX MAP NO. : Section Block Lot
CROSS _STREET: S-`/ LLLv 6 %64- /9--(J
TYPE OF SYSTEM: Septic Tank New. Existing
-- _ - Cesspool . New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:t- / S
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.)
>ra f
Sig ature of Applicant
RECEIVED BY:
Town C I ' fice
DATE:
crp-2 3 1991 .
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