HomeMy WebLinkAboutSmith (8) I1111a itis o;%.
,141, r&ky i VA 74
Town Hall, 53095 Main Road,
rit `' P.O. Box 1179
4:AA �� �i'� Southold, New York 11971
JUDITH T.TERRY ®� FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1317-R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
New Existing X
Name Of Owner SMITH, WILLIAM M.
Mailing Address 1 P.O. BOX 762
Mailing Address 2
City St Zip 1142 �-r1TIEkC4:— NY 11935-0000
Property Address 1 460 WOODCLIFF DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-734-7506
Tax Map No. section 1 .07 block 8 lot 12
Cross Street WESTVIEW DRIVE
Date Of Last Pump Out 7/01/88
Issue Date: 11/27/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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O'rFIC,E OF THE TOWN CLERK c��FFO(�'�'-
Town of Southold Q < ea ." Application No. /c3i7
Judith T. Terry, Town Clerk .0.4* 414
Town Hall, 53095 Main Road a $10.00 - Residential
P. O. Box 1179 cryb4 $25.00 - Non-Residential
Southold, New York 11971 O ® `
Telephone -T0/11144-' Oro/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE it/ / 2/
iAr
OWNER NAME: W f C—LI O 1
OWNER MAILING ADDRESS: p® 74,Z 4454 9J'5
OWNER PROPERTY ADDRESS: IA40 / -
OWNER TELEPHONE NUMBER: 73 4 �' n
TAX MAP NO. : Section 1/(17 Block Lot
CROSS STREET: (Lt 4A-6509
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,3k `1I1
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: _L%t7 ',
.wn ' Jerk' Office
DATE: ,�
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