HomeMy WebLinkAboutProvencher JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK , P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS y® . Fax (516) 765-1823
MARRIAGE OFFICER sj`' ® � Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER =_7®1 'Vol'
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3227-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner PROVENCHER, WILLIAM
Mailing Address 1 P. O. BOX 1749
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 53830 COUNTY ROAD 48
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4377
Tax Map No. section 52.00 block 2 lot 19.000
Cross Street BEVERLY ROAD
Issue Date: 8/01/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
fm. c
OFFICE OFTHE TOWN CLERK 'c3vFFD(,r�
Town of Southold k. t�k; -eV-, Application No. 33,-7
Judith T. Terry, Town Clerk MA -Lel
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 sA, $25.00 - Non-Residential
Southold, New York 11971
Telephone : .( y1 is
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ .10 : 0-0
DATEJ .1 , 99
OWNER NAME: tO rl ( B UY\ L. Pro r
OWNER MAILING ADDRESS: d . G )4. 41
So cl d ho l4 cN .v.
OWNER PROPERTY ADDRESS: IVO ' gj l jj l `1
OWNER TELEPHONE NUMBER: *76 5 T 3/ 1
TAX MAP NO. : Section 5-� Block Lot
CROSS STREET: 80\( € r LL- LY l al 61 Nk ,► I `7(y
TYPE OF SYSTEM: Septic Tank 1, New 1/ Existing
Cesspool New Existing
Residential V Non-Residential
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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2161-0 ffi-e_a -Q L j Com, . / , Signature of Applicant
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RECEIVED BY: •
Town Werk s Office
DATE: REFINED
JUL k 51994
Town auk Southold
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