HomeMy WebLinkAboutSmith 01 - Town Hall, 53095 Main Road
" � ��,. P.O. Box 1179
® #s" 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. 1004-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, CATHERINE ANN
Mailing Address 1 1520 BRAY AVENUE
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 1520 BRAY AVENUE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5113
Tax Map No. section 126.00 block 7 lot 27.000
Cross Street ALBO DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 2/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK aCOF0 it 1-
Town of Southold , A CQ ' , Application No. `00,?
Judith T. Terry, Town Clerk A- K r : G
Town Hall, 53095 Main Road ri .4. Residential
P. O. Box 1179 cn Non-Residential
Southold, New York 11971 �y�o ;
Telephone ''1�ll
(516) 765-1801 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 66
DATE jr (0 - 09
OWNER NAME: 0 (dT11ex1 r1�- 4 n I1 1`r k
ALJ 1 i n ` of n SS
OWNER MAILING ADDRESS: 16 p P �- Ave_•
LQkrei ) A . l / qL1
OWNER PROPERTY ADDRESS: J-5-Q10 Bj ray A-ye •
L6th r'_f , i y . ,) l 9 q
OWNER TELEPHONE NUMBER: „=6-7( - .29e - „5-
TAX MAP NO. : Section /024 Block 7 Lot o7 7
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing >/
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: / g8
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.)
a .
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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