HomeMy WebLinkAboutScheiner JUDITH T. TERRY ` Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
• REGISTRAR OF VITAL STATISTICS _ �� Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER , • •
y 0.°� 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. 3135-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New .Existing X
Name Of Owner SCHEINER, JACOB PAUL
Mailing Address 1 P. O. BOX 1285
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 275 WOOD END WAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2448
Tax Map No. section 70.00 block 11 lot 18.000
Cross Street PARKWAY
Date Of Last Pump Out 0/00/00
Issue Date: 10/14/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
Town of Southold • c31 II
� Application Nola/
Judith T. Terry, Town "Clerk` O
:r.:S;t4 c $10.00 - Residential
Town Hall, 53095 Main Road � ��•. *, �� .
P. O. Box 1179 - u-3 -':t 150,64 hti . $25.00 - Non-Residential
Southold, New York 11971 O :® '` ;'
Telephone 0( •10
-04
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ � cc?"'
DATE G '
'OWNER NAME:
OWNER MAILING ADDRESS: 7;7677G/� ,�, �JJ/LLi ' (J/12/ -.12
OWNER PROPERTY ADDRESS: -,2_57Q-C.°•4:) �,0Ce-il, i
OWNER TELEPHONE NUMBER: ":jj .76J)--'5"�7
TAX MAP NO. : Section Block Lot
CROSS STREET: /31¢k,4"*" y'
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool Li" New Existing L
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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