HomeMy WebLinkAboutProud 5
Town Hall, 53095 Main Road
P.O. Box 1179
�����` Southold, New York 11971
JUDITH T.TERRY _� _I.0 TELEPHONE
TOWN CLERK �� (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. 868-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner PROUD, GEOFFREY AND HELEN
Mailing Address 1 BOX 801
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3523
Tax Map No. section 18. 00 block 2 lot 27. 000
Cross Street PLATT ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/30/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
;i!
OFFICE OF THE TOWN CLERK tFOU.�'- '_
Town of Southold �� CQ Application No.
Judith T. Terry, Town Clerk .` f ;� �►
Town Hall, 53095 Main Road
rG ) Residential
P. O. Box 1179 � " �. e` �;' Non-Residential
Southold, New York 11971 O ® ` ��`
0�'
Telephone �j t �r
�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
- OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /V?
DATE
OWNER NAME: PR ® V
OWNER MAILING ADDRESS: (, ' g 6 1
sY 1
OWNER PROPERTY ADDRESS: V
0 ''i E `
OWNER TELEPHONE NUMBER: 31aa ,
TAX MAP NO. : Section Block Lot
CROSS STREET: ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ®,S�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,Qe4.0, 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: -
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