HomeMy WebLinkAboutSchmitz (2) tfUL
44 C3 A
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' x Town Hall, 53095 Main Road
„ P.O. Box 1179
® $' �.4 > Southold, New York 11971
JUDITH T.TERRY a/ji0'� TELEPHONE
TOWN CLERK (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. 909-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHMITZ, JAMES A.
Mailing Address 1 I EAST HUXLEY DRIVE
Mailing Address 2
City St Zip LLOYD HARBOR NY 11743-0000
Property Address 1 PECONIC BAY BOULEVARD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No . 516-421 -4249
Tax Map No . section 145 . 00 block 1 lot 4. 000
Cross Street OAK STREET
Date Of Last Pump Out 0/00/00
Issue Date: 11/09/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF' THE TOWN CLERK c0FOLA' n
Town of Southold � C� � Application No. 7 0/q
Judith T. Terry, Town Clerk ,„s, ,
Town Hall, 53095 Main Road `��'�l Residential
P. 0. Box 1179+, ':�� " i�; Non-Residential
Southold, New York 11971 ® rebi *�`
Telephone
(516) 765-1801
9. 7.. 95 TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
- for .
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
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T j r(�
OWNER NAME: J A, v" I t' A 5c., -/-71/141 /
Lj
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS: T
u--41 -1„t_4.(AJ/(
OWNER TELEPHONE NUMBER: �j (O L J — L ` I
TAX MAP NO. : Section /z/S Block j' Lot
CROSS STREET (4_, 4, L,e,„e_X-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V 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.)
1 i
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Signature • Asplicant /
RECEIVED BY:
Town Clerk's Office p�
„
DATE:
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