HomeMy WebLinkAboutSamuels r Town Hall 53095 Main Road
r c=. P.O. Box 1179
®��® s� �C��lie, Southold, New York 11971
JUDITH T.TERRY `-_ � �0:010�1, 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. 1389-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SAMUELS, THOMAS C.
Mailing Address 1 STEELMAN, NANCY L.
Mailing Address 2 25235 MAIN ROAD
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 NEW SUFFOLK ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6405
Tax Map No. section 117.00 block 6 lot 7.001
Cross Street FANNING ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/21/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
lFOUr
Town of Southold Application No. /217
Judith T. Terry, Town Clerk
� "'
Town Hall, 53095 Main Road ; .;� ;� $10.00 - Residential
P. O. Box 1179
�`
U' $25.00 - Non-Residential
Southold, New York 11971p'® '� r ��i'�$
Telephone Q( N
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE,,E% r o2e, /f7 d
OWNER NAME: .,)z2 /v a, /6142-tele / in?.,/ 0 )d t 6,z
•
OWNER MAILING ADDRESS: G,Zs�,3�
OWNER- PROPERTY ADDRESS:- i>?�v"' /-7 , ' .•
�2Zt�rl
OWNER TELEPHONE NUMBER: 7,� -
TAX MAP NO. : Section //ZOO Block ®Ca 00 Lot 0119740e3/
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
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.)
•
&BP/14W Olg2V/1444--e8
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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