HomeMy WebLinkAboutPark OFFICE OF THE TOWN CLERKic3��F�[�(�`,'
Town of Southold �� 5�
Judith T. Terry, Town Clerk At ' E , j
Town Hall, 53095 Main Road et.
P. 0. Box 1179 u) u
Southold, New York 11971 p ®
Telephone 9(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 331 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: William E. Park Jr.
OWNER MAILING ADDRESS: 3500 Pine Neck Rbad
Southold, New York 11971
OWNER PROPERTY ADDRESS: 3500 Pine Neck Road
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-3320
TAX MAP NO. : Section 70 Block 9 Lot 1
CROSS STREET: Bennetts Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X ' Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1977
Judith T. Terry
Southold Town Clerk
DATE: July 15, 1987
(TOWN SEAL) '
4 I Ili
OFFICE OF THE TOWN CLERK c31F�(� �- /
Town of Southold �� CQG' Application No?
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ,-.e, :'� Residential
P. O. Box 1179 v' ,� � Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 7 _ is- 1
OWNER NAME: 60, /��_� r Pmee
OWNER MAILING ADDRESS: 3 ro v A'n.e Alec% 0.
3,D,4-44,1 y X19 7/
OWNER PROPERTY ADDRESS: 3 .rot) the
)�
OWNER TELEPHONE NUMBER: ) 6 V- 3 3
TAX MAP NO. : Section "] 0 Block 9' Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: \ 1
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.)
POL4.t
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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