HomeMy WebLinkAboutShalvey (3) JUDITH T. TERRY �: �,� Town Hall, 53095 Main Road
TOWN CLERK I:CD
fi P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .: Southold, New York 11971
MARRIAGE OFFICER ‘VA, Fax (516) 765-1823
rYiLi0 � � Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1863-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SHALVEY BROS.
Mailing Address 1 200 BAY ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 25705 BRIDGE LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5153
Tax Map No. section 84.00 block 4 lot 11 .003
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 3/31/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OF'ihCE •OF THE TOWN CLERK 'clVFFf(,4-'-
Town of Southold �� RCQG- Application No. Af6 3
Judith T. Terry, Town Clerk " _
Town Hall, 53095 Main Road 01`,7 ,417:,
$10.00 - Residential
P. O. Box 1179 cn a r ' ► ;' $25.00 - Non-Residential
Southold, New York 11971 00 '�'�
Telephone O
( '9
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
�'1 -2--
OWNER NAME: 01vd
OWNER MAILING ADDRESS: GO WO LJ2
-/— S
- >O.JVNER- PROPE.RTIY .ADDRESS: - "9" -
OWNER TELEPHONE NUMBER: 73V—C:575--g 00Z. f T
TAX MAP NO. : Section % Block y Lot 7/ 3
CROSS STREET: $A, 0,9e Are ye- "
TYPE, OF:SYSTEM: ' Septic Tank- New Existing
Cesspool New Existing L/
Residential Non-Residential -
DATE OF PREVIOUS PUMP-OUT: ,,, U�✓�
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.)
014/__GY, ?'"Ia%
Signature of Applican
RECEIVED BY:
Town Clerk's Office
RECOVED-
DATE:
MAR3 1 12 ' '
Tom Clerk Southold
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