HomeMy WebLinkAboutRayOFFICE OF THE TOWN 'CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 301
Fee $ 10.00
NAME OF OWNER: Mary Ra
Residential X
Non -Residential
Septic Cesspool - X
OWNER MAILING ADDRESS: Factory Avenue
Mattituck New York 11952
OWNER PROPERTY ADDRESS: Factory Avenue
Mattituck New York 11952
OWNER TELEPHONE NUMBER: 516-298-4668
TAX MAP NO.: Section 122 Block 6 Lot
CROSS STREET: Main Road (Route 25)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New
Existing X_
Residential X Non -Residential
DATE OF PREVIOUS PUMP -OUT: February 29, 1987
DAT E; May 5. 1987
Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
OWNER NAME:
OWNER MAILING ADDRESS:
Application N o
Residential .�
Non -Residential
DATE o3-
OWNER
3-
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: Z161"�i O
TAX MAP NO.: Section /'n2- a-- Block 6 Lot �
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing k/
Residential ✓ Non -Residential
DATE OF PREVIOUS PUMP -OUT: A:;2a _ k,7
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.)
Signa r
re of A licant
RECEIVED BY:
R
tea r k' s O f, i ce
DATE: _ n�nV i 198
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