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HomeMy WebLinkAboutSmith (5) / 041 tr:4 JUDITH T. TERRY Town Hall, 53095 Main Road TOWN CLERK P.O. BOX 1179 REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971 MARRIAGE OFFICER � ® .- ®4r*,�1, Fax (516) 765-1823 ®.1 **4Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 2037-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner SMITH, MRS. HERBERT Mailing Address 1 P. O. BOX 654 Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address 1 275 MAIN BAYV I EW ROAD Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-765-3518 Tax Map No. section 70.00 block 5 lot 53.000 Cross Street PINE NECK ROAD Date Of Last Pump Out 0/00/80 Issue Date: 2/22/93 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK •S�FFO(,- = Town of Southold % . . CQ Application No. o�!/ Judith T. Terry, Town Clerk . �t�, LItt y _ Town Hall, 53095 Main RoadR ''-� '� $10.00 Residential P. O. Box 1179 u' s;_ AN.. hi . $25.00 - Non-Residential Southold, New York 11971 O Telephone 1 -4- 0);°.° • (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATIONPERMIT SEPTIC TANK or CESSPOOL Operation Permit No. • Fee $ DATE to/i ((IR, OWNER NAME: ''Y 15, er b i Si-ri i I h OWNER MAILING ADDRESS: Q (j f)( _ 5cjufhoIC''�� � i •y, 11Q`l OWNER PROPERTY ADDRESS: J -mClll1 15(3„utt)teu� R(t nufhnic , Nuy, i 1ql 1 . OWNER TELEPHONE NUMBER: ( i ) 7c,S-- 3518 TAX MAP NO. : Section '70 Block 6- Lot 6 3 CROSS STREET: flu N` e-c L�c� TYPE OF-SYSTEM: Septic.Tarik 7 New 6 Existing 4 Cesspool 1// New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: g-C.2 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 of Applicant RECEIVED-BY: --- • - Town ECEIVED-BY: --- Town Clerk's Office DATE: o O CO '