HomeMy WebLinkAboutReillyJUDITH T. TERRY
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Town Fall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
FAX (516) 765-1823
TELEPHONE (516) 765-1801
Operation Permit No.. 1031-R Residential X Non -Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner
Mailing Address 1
Mailing Address 2
City St Zip
Property Address 1
Property Address 2
City St Zip
Owner Telephone No.
Tax Map No. section
Cross Street
Date Of Last Pump Out
Issue Date: 2/22/89
REILLY, JANE ELIZABETH
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P. O. BOX 2
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SOUTHOLD NY 11971-0000
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1325 OAKLAWN AVENUE
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NY 11971-0000
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516-765-1504
70.00 block 3 lot 3.000
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MAIN ROAD
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0/00/00
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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 $ o o�
OWNER NAME:
OWNER MAILING ADDRESS: 1-0,42,6z,.4
Application No./ 3�
Residential 4__�
Non -Residential
DATE 1-2, dtua�7 / 9g9
OWNER PROPERTY ADDRESS:
_13_2_,!r_ !+-r/e'
c�50_7J a 0 Id
OWNER TELEPHONE NUMBER: 76-r /-rO
TAX MAP NO.: Section 70 Block
CROSS STREET: A/8, -e;
3 Lot -3
TYPE OF SYSTEM: Septic Tank ) New X Existing
Cesspool y New Existing :?_
Residential Non -Residential
ze
DATE OF PREVIOUS PUMP -OUT: /2/
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north w and feet
of distance, approximately, to building nd c sest road.)
4 7
Signature of Applicant
RECEIVED BY:
Town COierk's Office
DATE:
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