HomeMy WebLinkAboutRuggles �,oil OFF04,
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JUDITH T.TERRY ,t Gt Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
r? �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O �� Fax(516) 765-1823
MARRIAGE OFFICER . 1�
RECORDS MANAGEMENT OFFICER _�0,! * ��O��0i Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3660-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner RUGGLES, MITCHELL
Mailing Address 1 1150 NAKOMIS ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1150 NAKOMIS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4366
Tax Map No. section 78.00 block 3 lot 15.000
Cross Street HIAWATHA'S PATH
Issue Date: 7/23/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.OIFICE OF THE TOWN CLERK
Town of Southold �O � FO �
�Q =� Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ' $10.00 - Residential
P. O. Box 1179 z $25.00 - Non-Residential
Southold, New York 11971 O` � �`�
Telephone ( �� •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
f
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /— ?)
OWNER NAME: 1-/�jj��%G/
OWNER MAILING ADDRESS://l
4' 4 r /77
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER: X9 4((11U' •
TAX MAP NO. : Section 7 • Block 5 Lot /$
CROSS STREET: --� f Pc"Thl- 4
TYPE OF SYSTEM: Septic Tank 7 New Existing /
Cesspool P/ New Existing r//
Residential Non-Residential
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.)
lir
Signature of "'.licant
RECEIVED BY:
Town Clerk's Office
DATE: .
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