HomeMy WebLinkAboutSchmitz OFFICE OF THE TOWN CLERK I icalFO[,/t-
Town of Southold Q4 > ,f ljA
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Judith T. Terry, Town Clerk +'
Town Hall, 53095 Main Road 1 j
P. O. Box 1179 C�, ® ,
Southold, New York 11971 •
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- Telephone ®l s )\-
(516) 765-1801
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 413 Residential X
Fee $ 10.00 - Non-Residential .
Septic Cesspool 'X
- NAME OF OWNER: Arthur F. Schmitz
OWNER MAILING ADDRESS: 590 Haywaters Drive
Cutchoque, New York 11935
OWNER PROPERTY ADDRESS: 590 Haywaters Drive
Cutchogue, New York
OWNER TELEPHONE NUMBER: ' 516-734-5103
TAX -MAP NO.. : Section 104 Block 5 Lot 22
CROSS STREET: Mason Drive
TYPE OF SYSTEM: Septic Tank New 'Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 29, 1981
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Judth T. Terry
Southold Town Clerk
DATE: August 25, 1987 -
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`(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'c31FO� 4/43 .
Town of Southold % " Y _ j -. C��'� Application No.
Judith T. Terry, Town Clerk . ,,,et
�1t �`� Residential
Town Hall, 53095 Main Road = ,'
P. O. Box 1179 ` Non-Residential
Southold, New York 11971 O ,F •�
Telephone --4 i� �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4/3
Fee $/®
DATE
OWNER NAME: ii°'� `+' 7 / T�
OWNER MAILING ADDRESS: e . .� 41 _l
.1-- Ar z--, — Ali/ 77e/C- 3 '
OWNER PROPERTY ADDRESS: �1- c
OWNER TELEPHONE NUMBER: / /‘°— Z.. 7" —��/ 2.3'
TAX MAP NO. : Section 1'
Block 1.--- Lot 1 2--
CROSS STREET:
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool `� New Existing
Residential Non-Residential
- - DATE OF PREVIOUS PUMP-OUT: �;.ric !! 7 �,2 f
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LOCATION MAP: Must be attached hereto befdre permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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Signature of Applicant
RECEIVED BY: Cif
Town Cle s Offic
DATE: 1 - . S ter .
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