HomeMy WebLinkAboutSchultz OFFICE OF THE TOWN CLERK • •C���FQ���,"
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road , -
P. 0. Box 1179 w'
Southold, New York 11971 ti Q ®$ `• k,•%-- ••,
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 153 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
•
NAME OF OWNER: David P. Schultz
OWNER MAILING ADDRESS: P.O. Box 624
Mattituck, New YOrk 11952
OWNER PROPERTY ADDRESS: 2565 Wickham Avenue
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-9340
TAX MAP NO. : Section 139 Block 2 Lot 3
CROSS STREET: Granth Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 1986
Judith T. Terry 1/
Southold Town Clerk
DATE: Novmeber 19, 1986
(TOWN SEAL)
Ire
OFFICE OF THE TOWN CLERK COFUM-
C
Town of Southold Application No. /63
Judith T. Terry, Town Clerk . = .- , �f
,
Town Hall, 53095 Main Road �� ? -4 Residential
P. O. Box 1179 ' �i Non-Residential
Southold, New York 11971 O `
Telephone ( .•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
•
SEPTIC TANK or CESSPOOL •
Operation Permit No. As-3
Fee $ /b
DATE e-t &, L -7j
OWNER NAME: D54 Vii p sem/4.7-z_
OWNER MAILING ADDRESS: ,Q, O . I IOX 621-1
Mf4TT/ mak` , /, 1/. //y'5-2—
OWNER
OWNER PROPERTY ADDRESS: 256.5 6//C(44/9-M 11-11 ".
/17r i 7VC
OWNER TELEPHONE NUMBER: Z'9T=5: `t-'v
TAX MAP NO. : Section /3 y BlockLot 3
CROSS STREET: G2ti /119ii /9-V8 61T 00 SCUT L pF iQ,
4t , BR iberE
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool !/ New Existing !�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Jv.i / /95k'
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 Applican
RECEIVED BY: cr�,
Town �gerk's Office
DATE: NACEI N®
N 19M
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