HomeMy WebLinkAboutSimmons 1 '
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Town Hall, 53095 Main Road
a•' %59 � �, � '• P.O. Box 1179
®' 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. 1276-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIMMONS, STEPHEN H.
Mailing Address 1 1050 OAKWOOD DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1050 OAKWOOD DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2938
Tax Map No. section 70.00 block 12 lot 29.000
Cross Street PINE NECK & NORTH BAYVIEW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/19/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFO
Town of Southold . ., v:- CSG• Application No.16: -7(i
Judith T. Terry, Town Clerk . 2 max_
Town Hall, 53095 Main Road ` `" '' , :4 $10.00 - Residential
p. O. Box 1179 cn 4,
w .. � W.- � $25.00 - Non-Residential
Southold, New York 11971 O - v'` �$`
Telephone Q( , `��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for .
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Perit No.
Fee $ (0 / 157)
DATE / /cP
,
OWNER NAME: g..z S `
�f �'n/ a
OWNER MAILING ADDRESS: /', 19 69-4 4���C� ,1) )2lrC>e
4..e. ® , /r/, y //17/ -
OWNER PROPERTY ADDRESS: i9y#2i i9 s' "caa el_
OWNER TELEPHONE NUMBER: ,,. .: ,7,3 e
y TAX MAP NO. : Section PO Block i- Lot 7 7
CROSS STREET: / /,,�/e. ,47: -.-e , / �' ', ,' J dii La Pc(
TYPE OF SYSTEM: Septic Tank New Existing
_ Cesspool New Existing X
Residential X Non-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 road.)
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„Pi
Signature of Applicant
RECEIVED BY: if) I 0
Tow Clerk's Office
DATE: /b/) €7/23'
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