HomeMy WebLinkAboutSmith (5) 010 Oft.
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Town Hall, 53095 Main Road
P.O. Box 1179
k �® Southold, New York 11971
JUDITH T.TERRY = _® TELEPHONE
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1OWN CLERK � (516) 765-1801
REGISTRAR OF VITAL S FATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPiOSAL PERMIT
OPERATION PERMiIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 862-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, MARY HALLOCK
Mailing Address 1 WHITWELL, BARBARA ANN
Mailing Address 2 Y-5 L
City St Zip GILGO BEACH L NY 11702-4603
Property Address 1 PRIVATE LANE 17 4460
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-781-4009
Tax Map No. section 123 .00 block 6 lot 18. 000
Cross Street CAMP MINEOLA ROAD
Date Of Last Pump Out 8/00/81
Issue Date: 9/27/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKc�vFF0 gG
Town of Southold 0 1, C'� ' Application No.
Judith T. Terry, Town Clerk i •. y
• 1 Residential
Town Hall, 53095 Main Road
P. O. Box 1179 V. '�- i •' Non-Residential
Southold, New York 11971O%";Ti40-/
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Telephone
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O
DATE -./t • , c2O, /9
OWNER NAME:ipf}e f}-GLoc ' `:?;'Yjt/�/ 26197e-19 / ,444, laCLIV2cl622.-
OWNER MAILING AD RESS: /
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OWNER PROPERTY ADDRESS: �
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/:27,g7 T c-X
OWNER TELEPHONE NUMBER: i67, — 7,/ - 17106?
TAX MAP NO. : Section f42 3, Block Ca Lot IS
CROSS STREET: CA-J/7° /7'4-' 69 /iLD
TYPE OF SYSTEM: Septic Tank New • Existing
Cesspool New Existing X
Residential ,( Non-Residential
DATE OF PREVIOUS PUMP-OUT: #,e _.,../
LOCATION MAP: Must be attached hereto before ermitbe issued.
p may
(Locate building and system; give north arrow and feet
of distance, approximately!, to building and closest road.)
gnature of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE:
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