HomeMy WebLinkAboutSmall (41 COL tet,
Town Hall, 53095 Main Road
,�� P.O. Box 1179
,006: Southold, New York 11971
JUDITH T.TERRY = „,,�i%�'�� 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. 982-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMALL, GEORGE S. & BERTRICE W.
Mailing Address 1 P. O. BOX 968
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 575 CRITTENS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1268
Tax Map No. section 70.00 block 11 lot 5.000
Cross Street PARKWAY
Date Of Last Pump Out 0/00/00
Issue Date: 1/09/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK S�FFD(,t�'=
Town of Southold 0 -- Application No.
Judith T. Terry, Town Clerk �` _ •
Town Hall, 53095 Main Road Residential L-
P. O. Box 1179 t.n v Non-Residential
Southold, New York 11971 O`O1�`,
. T,elephone '/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT S
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. q
Fee $ /O. '�
DATE December 12� Inre
OWNER NAME: .L3 EbR& S . eiN4 SE,1RICE w, SMALL_
OWNER MAILING ADDRESS: P-0 . 1304 q6 g
Savin-10L c Iv y. 1 , q7 !
OWNER PROPERTY ADDRESS: S 7s` C R IYT ENs LANE
SOUTZ-I&LP , N- y- , I771
OWNER TELEPHONE NUMBER: 765- /2g 8
TAX MAP NO. : Section 70 Block Lot $
CROSS STREET: P 1g' R KwAy
- TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing ✓
Residential I/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: ioyewt6err 14168
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.)
d1-t441
ignature of Applicant
RECEIVED BY:
Town Clerk's Office ,
DATE: