HomeMy WebLinkAboutSmith (4) 40 00%\\IFwJ
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, vs ^�' Town Hall, 53095 Main Road
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---.7,01 Southold, New York 11971
JUDITH T.TERRY —...wo0r�� TELEPHONE
TOWN CLERK (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. 659-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, MARY ANNA
Mailing Address 1 P.O. BOX 146
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2130 GRAND AEENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000 -
Owner Telephone No. 516-298-8414
Tax Map No. section 107. 00 block 3 lot 17. 000
Cross Street BROWER ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/25/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�U�FO(r- '
Town of Southold �® �Q,' Application
Judith T. Terry, Town Clerk
Residential
Town Hall, 53095 Main Road ® T4' '
P. O. Box 1179 c' . ' '��, Non-Residential
Southold, New York 11971 o�id
Telephone _®1 * ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /Y/")'RGA 42,3 119 D 0 .
OWNER NAME: SMI) fy ,9!-JV/V,1 3n,�
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rht
OWNER MAILING ADDRESS: D.gaX /if-4
irs
OWNER PROPERTY ADDRESS: g/3 (� g/?f9f/Gl ,4L'E
j41,41 ?ri r vck� yy
OWNER TELEPHONE NUMBER: e"./` 9��
TAX MAP NO. : Section / O 7 Block Lot / 7
CROSS STREET: ,Ga)a ./. o ()0 • / /?t.ad4 )
C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential i7 Non-Residential
DATE OF PREVIOUS PUMP-OUT: re b. 9 / yrs,
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.)
`1 i n of A licant
G�� re P p
RECEIVED B * �_. L6,
7.wn Clfrk's Of ice
DATE: Ali 2 51999
'Town Clerk Southold
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