HomeMy WebLinkAboutRand Town Hall, 53095 Main Road
,po® P.O. Box 1179
l‘nIIs! Southold, New York 11971
JUDITH T.TERRY
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. 1272-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RAND, CHARLES AND LAURA
Mailing Address 1 P. O. BOX 1938
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 360 TUCKERS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5453
Tax Map No. section 63.00 block 5 lot 5.000
Cross Street GRISOWLD
Date Of Last Pump Out 0/00/00
Issue Date: 10/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK , al FOU, '-
Town of Southold � C'� ' Application No. /D2$7 Y
Judith T. Terry, Town Clerk h y
Town Hall, 53095 Main Road z;�x } $10.00 - Residential
P. O. Box 1179 (1] $�K �• r
� �•• 25.00 - Non-Residential
Southold, New York 11971 O 'tS
Telephone �( y
(516) 765-1801
TOWN OF SOUTHOLD
REC
.0 CT 03 iSt39 SOUTHOLD WASTEWATER DISPOSAL DISTRICT
TQC Clerk Sou4h_OAil
APPLICATION
- for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O, 00
DATE c.51—Pre—d418 JI
OWNER NAME: ( 9 4 /Auto 6,010 • •
OWNER MAILING ADDRESS: Po.
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OWNER PROPERTY ADDRESS: O 7��,C'�°� J3J T R° 2 2
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OWNER TELEPHONE NUMBER: '370 4s1":: 5'45-3
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TAX MAP NO. : Section 6 3 Block — 5 Lot
CROSS STREET: 6450.0li,)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing V
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: „e1/44AJI)
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 Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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