HomeMy WebLinkAboutPotts ',I 411`x] 9 01. ...
6411(‘C)
frt ran Town Hall, 53095 Main Road
44/
,��' P.O. Box 1179
�® 18i!$A.011 Southold, New York 11971
JUDITH T.TERRY „,„fir°°' FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1521-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner POTTS, WILLIAM J. JR. & ANNE M.
Mailing Address 1 6435 WISCASSET ROAD
Mailing Address 2
City St Zip BETHESDA MD 20816-0000
Property Address 1 WEST SHORE DRIVE
Property Address 2 (PARADISE SHORES ROAD)
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 301-229-6310
Tax Map No. section 80.00 block 1 lot 4.000
Cross Street OAK DRIVE
Date Of Last Pump Out 8/00/83
Issue Date: 8/27/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OF;Z;ICE •OF THE TOWN CLERK •OF0IL '-
Town of Southold � ,.. CSG•, Application No,. /5-02./
Judith T. Terry, Town Clerk r ` A $10.00 - Residential
Town Hall, 53095 Main Road + ` } .
P. O. Box 1179 Cl) < - -. r�: ,5i $25.00 - Non-Residential
Southold, New York 11971 O�` s ; `'��••$
Telephone : j 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee .$ /0.00
DATE Av4-UST 2d) //IC,
OWNER NAME: Wil--1-1A-g4 Po7DS, ,40vo AA)A/ m . Po77S
•
OWNER MAILING ADDRESS: 643r WISCASSEr •
3ETh}-CSDA , f21B X08/(0
wEs�r site 9RE Di2L V
_ _ _ OWNER PROPERTY ADDRESS: (-PARADISE SE.tisiReS `P-.0A4
So civ14 L...b, N `/ /14 r/
OWNER TELEPHONE NUMBER: ( 30 /) 2-Z /— GVO
TAX MAP NO. : Section 8 Block / Lot C9 174
CROSS STREET: /.907" A p/0L1 C/ &LE
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /4114-057) i' 83
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 pplicant
RECEIVED BY: buw �e,�--�
TA nvClerkwk's�Office
NOV+x 41)
DATE:
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j�'v The water supply & sewage disposal sys-`Ys—
terns for this residence will conform to the ie
standards of the Suffolk County Depart- -
•4104, 61,9 ment of Health Services.
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P. O. BOX 909 "---
5.46_5.5 MAIN ROAD
S'OUTHOL D N. Y. 11971�
87- 525