HomeMy WebLinkAboutShibley OFFICE OF THE TOWN CLERK ' •c.0FRift.
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Town of Southold 0�`� h,
Judith T. Terry, Town Clerk % "` t.%
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Town Hall, 53095 Main Road
P. 0. Box 117 9 •
Southold, New York 11971 Q •
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Telephone .. M as- ''
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
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Operation Permit No. 191 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Walter Shibley
OWNER MAILING ADDRESS: P.O. Box 44
New Suffolk, New York 11956
OWNER PROPERTY ADDRESS: 1230 Fourth Street
New Suffolk ,New York
OWNER TELEPHONE NUMBER: 526-734-6673
TAX MAP NO. : Section 117 Block 7 Lot 7
CROSS STREET: Orchard/King
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New + Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: October 16, 1986
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Judith T. Terry
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Southold Town Clerk
DATE: January 6. 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0 Mire �;
Town of Southold �� CQ ' Application No. ,C,LL '
Judith T. Terry, Town Clerk .` ?'
Town Hall, 53095 Main Road 4° Residential
P. O. Box 1179 �' :' _ Non-Residential
Southold, New York 11971 4�i ,r `� ~, ‘t- •1�`
Telephone _o.( j � '•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 6--6
DATE a J- /1/
OWNER NAME: jV,L.-1-(e .5'W l•B 4,EY
OWNER MAILING ADDRESS: /)oj tboX
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OWNER PROPERTY ADDRESS: 152 g070(4/ ` S7'
OWNER TELEPHONE NUMBER: (/t - 73/--6r7,-
TAX MAP NO. : Section l 15 Block 7 Lot 7
CROSS STREET: o/-/,q1O
TYPE OF SYSTEM: Septic Tank ! New Existing I/
Cesspool New Existing
Residential Non-Residential
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DATE OF PREVIOUS PUMP-OUT: `D — /6 0
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 Applicant
RECEIVED BY: °wr i, ;,
Tow C erk's Ofice
DATE:
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