HomeMy WebLinkAboutSmith (2) .
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JUDITH T.TERRY ��/IP y� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
k rri �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER '='s4t %Or of Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER ®.' �.,d' Telephone (516) 765-1800
FREEDOM OF INFORMATION OFFICER sio
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3494-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SMITH, BRIAN & DEBORAH O'BRIEN
Mailing Address 1 21 LACE LANE
Mailing Address 2
City St Zip WESTBURY NY 11590-0000
Property Address 1 400 SMITH DRIVE NORTH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-334-0196
Tax Map No. section 76.00 block 2 lot 17.000
Cross Street BAYVIEW AVENUE
Issue Date: 8/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKcFFO
Town of Southold ��� 422 It\ Application Noc /(,
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Judith T. Terry, Town Clerk �� ,4x' `, ,
Town Hall, 53095 Main Road r $10.00 - Residential
P. O. Box 1179NY{ k1R; ,_° ' ► i' $25.00 - Non-Residential -�
Southold, New York 11971 O r 5 �`
Telephone • '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATES 9
OWNER NAME: er ft A) 7- ` — 5~7e?
OWNER MAILING ADDRESS: l
OWNER PROPERTY ADDRESS : 0 5-144.,72 rJ v. I1/41 _
'_ / �' 111'7<_
OWNER TELEPHONE NUMBER: L'•e474,9_
4 3/f ,o/q;,,
TAX MAP NO. : Section 7 6, Block Lot / 7
CROSS STREET: Al t/s72.�
TYPE OF -SYSTEM:- Septic--Tank-- --• New Existing,
Cesspool V New Existing
Residential Non-Residential
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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Signature of Applicant
RECEIVED BY:,_ „
Town Clerk's Office . '
DATE: -
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`'_ _ i _ .- ;1 '...--„•_/. � "•,, ,' 1 i ?_ lO THIS SURVEY IS A VIOLATION OF 1
' _ '-'-- ' - ---- - ; • — SECTION 7209 OF THE NEW YORK STATE 1
- EDUCATION LAW
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i COPIES OF THIS SURVEY MAP NOT MARIA
- - _ _ _ -- - - _ _ —_ -^-_--- - _ THd LAND SUPYE(OR'S INKED SEAL OE t
- - -\_r'\\:'I !--1-. ,J f:,'LOSSED SEAL SHALL NOT BE COIZ110tt§D
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r �✓ ti , .-`.P' , ) J . :( . . • ,c1AP.ANTEES INDICATED HEREON SHALL RUN
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- —--.__ _------- _. _ __---- "--------- — -�_GvIY_:O THE PERSON FOP.WHOM THE '�VEY
- - I --,-- - --�--<-_. v --'"-'- '- "-- f IS Pia??PED, AND ON HIS BEHALF TO TPIE',
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---s.•_-----___ -_- ---- _-___; _ _ - � - �j ;Ink COMPAM,GOVERDMENTAL AGEhtY.ANT
I I _ -- - - - - --- tENDIN G INSTITUTION LISTED N:9 1, A?10
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L'-"__ • 'HE ASSIGNEES OF THE LENDING R�6T1-`
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