HomeMy WebLinkAboutPainter JUDITH T. TERRY /4/# Town Hall, 53095 Main Road
TOWN CLERK _ i P.O. Box 1179
REGISTRAR OF VITAL STATISTICS T ► Southold, New York 11971
MARRIAGE OFFICER '�� Fax (516) 765-1823
®�'�1 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. 1659-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PAINTER, ROBERTA S.
Mailing Address 1 150 MEADOW STREET
Mailing Address 2
City St Zip GARDEN CITY NY 11530-0000
Property Address 1 26 SANDY BEACH ROAD
Property Address 2
'City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1066
Tax Map No. section 3.00 block 3 lot 4.001
Cross Street BEACH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERKPFFD
Town of Southold ��� �C'� Application No/6S
Judith T. Terry, Town Clerk ZA
Town Hall, 53095 Main Road • ` ' r� = :< $10.00 - Residential
P. O. Box 1179 cry :. $25.00 - Non-Residential
Southold, New York 11971 O "� �•
TelephoneIPA
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
4A for
MAR 21 18E1 OPERATION PERMIT
r:',461a SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0,'
DATE /7-)L t, _i_,
OWNER NAME:
OWNER MAILING ADDRESS: !.6-'o -J,/ ��
,_ j _ 7 //6-3"0
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: g_t„ -
TAX MAP NO. : Section 6 O 3 Block 0 3 Lot 00
CROSS STREET: ,664___
TYPE
I
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool i/ New Existing ✓
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: 2
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 Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
. .Nw-w+'e....•..—.."+�--.cn.."w. .-....- "�-r--w.,
zri '; " f: •' q TOWPLOf y'SOUTHOLD',
"•4';�,A�;, ,'t,;.;{` n- - ,,;,;-'�.7;2.a,,' ti`.t''x -k7: Ticket No. b 0 6 3
ro ,.v; �,,;u;,.-0,1,-,, -,;„,:°,,.',,, ,. ,k ,, ��.�, r'is i"' �^:.`,+'3"+' , "' 1 '. `��+- ♦q
4;1 y ``' ,; �1 `n" X01:: .t,, - d:' ,N;,,,,,,i;:^< '.j"` , , " A,• 1•,.1
i" r .� ` 7 - r.� "a, y..14 :: ��.i..x. "' ,-`9
, l''�tj`ncr',„� _ ny-' • �'` 4 f', ',./----,:•,,-�. `,:?:',.C- .'•%-.) LSC' _ - - • = - r rsu:e''t
;,-''':' '.SCAVENGER WASTE'R1EPORT � `� Fee:" $.02 per gallon . ;
=-01,,X.1
i1 - Fee $.C. ,. u paid •
Name of Hauler • Date .��G. .�6 paid
• Permit Number / Southold Town Clerk
Truck.Capacity.'. . PO.C), , Gallons Liquid Waste
., Date Pumped 3,/ 1 ,
, Residential . : :(. •Comm'ercial . Restaurant
'''`' ❑-SPLIT LOAD @ " Gallon's =
Location: . �• , . _
,
,;�:,, ,. , Name of Owner. / V �- ✓,�!�,
.,,.. - ,_•Street . RC1 . ,. a. ,�. . . -:., .7. oG Hamlet. C2.,� '�!a� ,
:, , . r'' Telephone Number'i ^.1, . Tax Map Number ' - -s " 'y/
Cross Street: . . . :: CO, , _
, Diagram (locating_ building, and cesspoole north arrow and ,feet of distance,
'approxim ately`.)
r4,
:,',-`_ - ' --; '' -".',' ='-- - ‘, ', -_.,:5749-4,cclr' ,6,42-ct'ed i4cP ' '
- • ,
y... ,
I: hereby:certify,that the above originated.within the,Town-of Southold/Town of Shelter
,:':,.Island ,at'the above' location(sj,arid to the best of my'knowledge, contains no chemicals, ,
•
t" - hazardous; or toxic -wastes. 'False statements made herein are punishable as a mis-
'` ' demeanor pursuant to Section 210-45 of the Penal Law of the State of New York, and ••
.,, .,,` may:result in-my arrest and the i .,
� dment-of the vehicle I am driving.
' ' - - Name of Driver . ,
- - • - Signature of Driver ' - ,-- ,
" - � Received by. . .
/2./..)ti_e
. Datev . . . . . .Time ,
r - " (1) Treatment Plant