HomeMy WebLinkAboutSmith (10) JUDITH T. TERRYTown Hall, 53095 Main Road
TOWN CLERK rrZ P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS .` Southold, New York 11971
y''% Fax (516) 765-1823
MARRIAGE OFFICER ®� r
',y,0 N o� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3011-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SMITH, THOMAS
Mailing Address 1 P. O. BOX 895 -
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2505 CAMP MINEOLA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8542
Tax Map No. section 123.00 block 6 lot 8.001
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/29/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFGE OF THE TOWN CLERK es���jJ
Town of Southold V �CQG' , Application No.0)0/7
Judith T. Terry, Town Clerk t f�j 'a
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 v' `"" {� ' $25.00 - Non-Residential
Southold, New York 11971 O _..�Y►'.-�0�.
Telephone 1 .6
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for' - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
-
Operation Permit No. ••
- ---- --- ------- - ---
Fee $ • - -
- - DATE 11// 9 3
OWNER NAME: ct-S .Sen ,`)L-6
OWNER MAILING ADDRESS: Qo' - 9.-S-Orcelhal,0 e?ifr..er/e-4.. deed
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OWNER PROPERTY ADDRESS: D-SM S— � dip 7 4,,cd4
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OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section t2') Block - Lot T. f
CROSS STREET:
TYPE -OF- SYSTEM.: Septic Tank New Existing
Cesspool- - New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: r2 Uvs ,..d"thee-
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 Clerk's Office
DATE:
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