HomeMy WebLinkAboutSchmidt (2) • . Il-i�,,
OFFICE OF THE TOWN CLERK JUTFQ�"C'
Town of Southold obiA.
,_
Judith T. Terry, Town Clerk r�xh
Town Hall, 53095 Main Road oy4,4„ �,
P. O. Box 1179 �,�ct� �'" ell
Southold, New York 11971
Telephone _ d
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 560 Residential x
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: John J. and Rita Schmidt
OWNER MAILING ADDRESS: P.O. Box 152A. West View Drive
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: 4500 Westphalia Road
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-4981
TAX MAP NO. : Section 113 Block 11 Lot 13
CROSS STREET: Meday Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing X
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Ter
Southold Town Clerk
DATE: January 5, 1988
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK '��FFOUr -
Town of Southold �� CQG Application No. 0
Judith T. Terry, Town Clerk411.
Town Hall, 53095 Main Road P " ..G Residential
P. O. Box 1179 te•
a.: ,�� ; ' �: Non-Residential
Southold, New York 11971 O ®cFf'. ��•`
Telephone el Ni •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
' DATE
OWNER NAME: a/-',1/ 4.- V- '-e 74i. cre%n;p7
OWNER MAILING ADDRESS: R,Q, ex /S ZA /A4sT 21ie.w D,-,ve
MA-%Ti TGi-GKj y //
Li 5-00 t J /1/9 //1-
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 6-4
TAX MAP NO. : Section // ,3 Block `( Lot J3
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,acv- �7
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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