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HomeMy WebLinkAboutRoache JUDITH T. TERRY A w_, Town Hall, 53095 Main Road TOWN CLERK ' <�;} :;' P.O. Box 1179 Southold, New York 11971 REGISTRAR OF VITAL STATISTICS a" �®�+� ' ��, Fax (516) 765-1823 MARRIAGE OFFICER ' ellir Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1776-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner ROACHE, PETER T. Mailing Address 1 P. O. BOX 144 Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 PECONIC BAY BLVD. Property Address 2 City St Zip LAUREL NY 11948-0000 Owner Telephone No. 516-298-9128 Tax Map No. section 126.00 block 10 lot 11 .000 Cross Street BRAY AVNEUE Date Of Last Pump Out 0/00/69 Issue Date: 10/04/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) • •.- • J)W 'I E OF THE TOWN CLERK OFU/b- - Town of Southold .V.,4-=!;-`, "0-- Application No. 1 7 7.6 Judith T. Terry, Town Clerk �� 1 . ) $10.00 - Residential Town Hall, 53095 Main Road o Z : - � � P. O. Box 1179 �"�.•�•:•� �� � ��` $25.00 - Non-Residential Southold, New York 11971 O � Telephone _ 1 (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ DATE Cc-fo be t--3 )Qe:i OWNER NAME: ?eA 1�— D�GI'1 P OWNER MAILING ADDRESS: Via )( D14 Mc�-4-1- kct5 OWNER PROPERTY ADDRESS: '-‘ ).e.-40114.0_/ BaitEAUC'X r-e_A L ItJ,Q. OWNER TELEPHONE NUMBER: - Z,,G( �s I Z( TAX MAP NO. : Section tat, Block 1a Lot x) !yo CROSS STREET: . C. ©- rimy- Q V e TYPE OF SYSTEM: Septic Tank New Existing _ Cesspool / New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: •� ' i • ," - • u ► • 1,dp, 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.) Signature of Applicant RECEIVED BY: Rati}QvpDClerk's Office DATE: OCT 041991 Town Clerk Southold