HomeMy WebLinkAboutScott (5) G �
JUDITH T.TERRY toFolir
��� ��: Town Hall, 53095 Main Road
TOWN CLERK ; y Z P.O. Box 1179
w S i Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ‘,'4
� ,� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER : 01 `�e►a,• Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,,••��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3536-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SCOTT, ROBERT I . JR.
Mailing Address 1 26700 MAIN ROAD
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 26700 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2730
Tax Map No. section 18.00 block 6 lot 17.005
Cross Street PLATT ROAD
Issue Date: 10/25/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •cvFFO(,r "
Town of Southold �� COQ Application No3 �
Judith T. Terry, Town Clerk �� +• "'°;ye`, ;�•
Town Hall, 53095 Main Road "' $10.00 - Residential vy
P. O. Box 1179 v' .*;#° h+ "" i' $25.00 - Non-Residential
Southold, New York 11971 •
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'Telephone
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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 $ •
DATE /0/2-4/q6
OWNER NAME: o�3�C � Gcm-T 3f,
OWNER MAILING ADDRESS:_ 2fo�'L0O V11 ,,.. w
God_«AfsA N N.
OWNER PROPERTY ADDRESS : ILAQ ctS ,_[Q.' 3.11_l
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OWNER TELEPHONE NUMBER: 1C0S-(g37 (o )
TAX MAP NO. : Section g " Blocic (, Lot ( 7,j
CROSS STREET.: Roa Q4Q
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool \/ New Existing
Residential / Non-Residential
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.)
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Signature of App ican
RECEIVED BY:
ow Clerk's Office
DATE: /b/c/
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