HomeMy WebLinkAboutGuy t V I� Town Hall, 53095 Main Road
�® . i`' P.O. Box 1179
®� ®•Southold, New York 11971
i/�f° FAX(516)765-1823
JUDITH T.TERRY �,�,,,ir/
TOWN CLERK TELEPHONE(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. 1010-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GUY, ROBERT J R.
Mailing Address 1 P. O. BOX 37
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 365 SEAWOOD DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3128
Tax Map No. section 88.00 block 2 lot 1 .000
Cross Street MIDLAND PARKWAY
Date Of Last Pump Out 0/00/00
Issue Date: 2/08/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK ' \\FFA' r
Town of Southold Q� �� Application No.
Judith T. Terry, Town Clerk c- r.. ►`
Town Hall, 53095 Main Road Residential idential L—
P. 0. Box 1179 cn ? moi ; Non-Residential
Southold, New York 11971 Otf
Telephone -*0/4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ !� •
•
DATE (". .2/7/1?
9
OWNER NAME: / /9 5k�27 G() / Te-
OWNER
l-OWNER MAILING ADDRESS: BO K 3�
o / 7C z- o At, -r /l y7/
OWNER PROPERTY ADDRESS: 3i,.S S'E"RG, D D PP
c:S'av 71/0 )7/- //f7/
OWNER TELEPHONE NUMBER: � �� a /�� /
TAX MAP NO. : Section 15 `k "Block Lot /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank ' ' New Existing r/
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.)
teteeLam! ,r—
Signature of Ap.lic t
RECEIVED BY: iC ,Q
Town C erk's Offi e
DATE:
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