HomeMy WebLinkAboutSmith .
JUDITH T. TERRY 'tez , Town Hall, 53095 Main Road
TOWN CLERK !' P.O. Box 1179
fir i�
Southold New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER '�, Fax (516) 765-1823
_ �® � 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. 1672-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, ALFRED
Mailing Address 1 29575 NORTH ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 29575 NORTH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-5404
Tax Map No. section 74.00 block 1 lot 40.002
Cross Street BRIDGE LANE/HENRY'S LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/22/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
ti
1 * IIS
OFFICE OF THE TOWN CLERK \\M
Town of Southold OROSCQG Application No. /6
Judith T. Terry, Town Clerkkt. v
Town Hall, 53095 Main Road : $10.00 - Residential
P. O. Box 1179 (r) rO . - $25.00 - Non-Residential
Southold, New York 11971 O�® r ;� " o
Telephone 01
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE f.72...z./f/
OWNER NAME: A( d �G?i/ (A
OWNER MAMLING ADDRESS: S-7 cS7N(i 1, T�.
,vim-vu �
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER: �� Q7y--
TAX MAP NO. : Section 751. Block Lot 4,d a
CROSS STREET: f3e. 44 j f/42, t' (14.t /14P-44.r-v1vS
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /f fp
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.)
ignat re of Applic nt
RECEIVED BY: �-��2 C J
Town lerk's Office
DATE: 1141/9(-
w: k
1 „------->
E
d.--____
r r
r,
- „„