HomeMy WebLinkAboutRauseoJUDITH T. TERRY
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3118-R Residential X Non -Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RAUSEO, OURANIA
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Mailing Address 1 1205 SUMMIT DRIVE
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Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
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Property Address 1 1205 SUMMIT DRIVE
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Property Address 2
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City St Zip MATTITUCK NY 11952-0000
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Owner Telephone No. 516-298-5620
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Tax Map No. section 99.00 block 2_ lot 13.000
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Cross Street INLET DRIVE
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Date Of Last Pump Out 0/00/00
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (516) 765-1823
Telephone (516) 765-1801
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Issue Date: 9/23/93 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
41
l
OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
Application • No.
$10.00 - Residential
$25.00 - Non -Residential
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ la
DATE 0
OWNER NAME:
3 -DIGIT 119
OWNER MAILING ADDRESS: HL93D 626 8000000068.1
OURAMIA RAUSEO
1205 „SUMMIT DR
�MATTITUCK MY 11952-1083 f
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
7 TAX MAP NO.: Section ' Block Lot
CROSS STREET: i�� �� -� ,f,,uje-�
TYPE -'OF- -SYSTEM: Septic Tank New Existing l
Cesspool New Existing �✓'
Residential r on -Residential
DATE OF PREVIOUS PUMP -OUT':
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 roads
RECEIVED BY:
Town Clerk's Office
DATE:
gnature of Applicant
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