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HomeMy WebLinkAboutSimon (2) or OVOLIr.1"b% el eti JUDITH T. TERRY ;` 11.• Town Hall, 53095 Main Road TOWN CLERK • Z P.O. Box 1179 REGISTRAR OF VITAL STATISTICS , Southold, New York 11971 MARRIAGE OFFICER �® ��` Fax (516) 765-1823 1 i�®I��' Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1806-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New X Existing Name Of Owner SIMON, ROBERT K. Mailing Address 1 25 20TH STREET Mailing Address 2 City St Zip JERICHO NY 11753-0000 Property Address 1 R.O.W. OFF WOOD LANE Property Address 2 City St Zip PECONIC NY 11958-0000 Owner Telephone No. 516-433-1298 Tax Map No. section 86.00 block 6 lot 3.001 Cross Street INDIAN NECK LANE Date Of Last Pump Out 0/00/00 Issue Date: 11/15/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) . ��� II OFFICE OF THE TOWN CLERK • OtA- Town of Southold � �_ C� Application No. W445 Juuith T. Terry, Town Clerk t4:1 Town Hall, 53095 Main Road `{ $10.00 - Residential u-� it* `�,�4,�-tri: P. O. Box 1179 s $25.00 - Non-Residential 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. /f?J Fee $ DATE /0/30/9/ • OWNER NAME: li:2o6 6.,e,— .1/45"/ Ai ay✓ • OWNER MAILING ADDRESS: - 20+71 71-r-.e8f- Ei J, \l / / 7 S OWNER PROPERTY ADDRESS : , (:.L2,� , �"7' B.L 04 L late. c Akeve Apvtic OWNER TELEPHONE NUMBER: '- 1/33 /z 98 TAX MAP NO. : Section 6G, av Block 6 Lot 3, Doi CROSS STREET: • re')D, /VC cfc c TYPE OF SYSTEM: Septic Tank New o✓ Existing Cesspool New Existing Residential I/ Non-Residential DATE OF PREVIOUS PUMP-OUT:, ,i 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.) Signature . Applicant RECEIVED BY: Town Clerk's Office DATE: • F - SUFFOLK CO. HEALTH DEPT. APPROVAL • - - -• . -<�-=' - • - = _ H.S. N0. �� .'...,..:1"-: - - �' o •,y�" s."-may - �-,- ,am. - ... - : _ - ° F. ' `� ' F• r' - r' • f,^ . ;- ' '•:„;,. ,' ""' r �'_ STA t' {V{ENT 'QF-IN7'EIT` , /t Q \ . ;' ,r ., �''„ l�' - . w. _f ,n ''..4''''',"'.--'-'-- ms's.*.c+,x-•_rs , • �" sir . ) T. -•-,'� - THE WATER=SUPPLY-:AND SEWAGE DISPOSAL ---- -'-.......r„-- - 1....:-.'";;;;4-:".. ,+,, rt .+ ,-`=- - •-- .�.+.%:. - ter. -:a.-:.,�:.�,q.�..-^---- { , - �,.t' ^ rte' 'SYSTEMS- ,FOR THIS -RESIDENCE WILL . ,�, - '` , r :�` � ,• ` u ro F j �2;�: CQt11FO M 'T °THE ANDARDS' OF THE ., = �,CNk~ - - �.r : SUFFOLK Co 't PT:`tOF.':HEALTH-SERVICES. Q,�,/ :l,,./�Y$y./+ t �� r { ^ E- fes' s - , ...• :i'` f 'y{f[+-+we }�.-r",1 •.' ""y, j/ },(l yy{{ (�'�� '• ��•.. . t- - f-- APPLICANT - _. -Y. „ {)j '`''r Oma, ..r•".1,. y}' 1 t 3.''.. �"/ ; ! ..f• - •i _ _ -^�fR 'IN - .'i - F4_ L,'=_,`,', -. 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