HomeMy WebLinkAboutRollins il 1 0Li
JUDITH T. TERRY
�� �® Gy Town Hall, 53095 Main Road
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TOWN CLERK Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS v rSouthold, New York 11971
MARRIAGE OFFICER ' Fax (516) 765-1823
® VTelephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1676-R Residential X Non-Residential
-- Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROLLINS, MARK L. SR. & ANOTHER
Mailing Address 1 P. O. BOX 1417
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 205 MAPLE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8853
Tax Map No. section 107.00 block 2 lot 10.001
Cross Street CRANK AVENUE
Date Of Last Pump Out 0/00/38
Issue Date: 4/29/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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'EV OF THE TOWN CLERK C���FO(,r
.r' Town of Southold � CD = Application No. g07(9" -
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road `` ' " $10.00 - Residential
O. Box 1179 = y `'" i
P. � -'��-�� '••-�'� $25.00 - Non-Residential
Southold, New York 11971 O�i-® . ���`
Telephone 10/ .a0 I'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ll Fj� z= , 1q9(
OWNER NAME: r1rn aw � o (;‘,7 .S S r 27t 4-,va •
OWNER MAILING ADDRESS: f 0 �S' " " / `/-
.f- .k. N N ( 9s-
OWNER
sOWNER PROPERTY ADDRESS:`--; `).® elf) (l, 1.1A
4rt k
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block Lot
CROSS STREET: G—•rq, L
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: -
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