HomeMy WebLinkAboutRivera C3 ea =
Town Hall, 53095 Main Road
ss,
P.O. Box 1179
�-_ ss22 Southold, New York 11971
JUDITH T.TERRY — ®� �S ��'. FAX(516)765-1823
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. 1;?80-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RIVERA, CHRISTINE
Mailing Address 1 22 WILLETTS COURT
Mailing Address 2
City St Zip ROCKVILLE CENTRE NY 11570-0000
Property Address 1 250 SOUND BEACH DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-766-0097
Tax Map No. section 99.00 block 1 lot 16.000
Cross Street INLET DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
aY • •��
OFFICE OF THE TOWN CLERK •c3\ FO/A-
Town of Southold � C��•• Application No✓�ltO
Judith T. Terry, Town Clerk 4 4
Town Hall, 53095 Main Road 8 rG $10.00 - Residential
P. O. Box 1179 3; i'�; $25.00 - Non-Residential
Southold, New York 11971 O "®
Telephone OI v •�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ":111.5
OWNER NAME: e/C•r ic,s-eq..
OWNER MAILING ADDRESS: o2,V 60e)fe/6-74 C11
�1�o►cicai'/lam C e004-', .'7 //T 2
OWNER PROPERTY ADDRESS: •Are_ /g
/ '7 J i / e 4/11
OWNER TELEPHONE NUMBER: S' 766, '.0U7
TAX MAP NO. : Section Block r Lot /0
CROSS STREET: g* - .
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool , - New Existing 4---s
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.)
Signat e of Applicant
RECEIVED BY:
Town Clerk's Office -
DATE: -
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Ste, ae.4114.