HomeMy WebLinkAboutSmith (9) •
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rTE{ y �+ Town Hall, 53095 Main Road
1 �i� �r P.O. Box 1179
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��� Southold, New York 11971
JUDITH T.TERRY :� = FAX(516)765-1823
TOWN CLERK ' ••iI0 TELEPHONE(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. 1354-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WILLIAM P. SMITH
Mailing Address 1 P.O. BOX 1198
Mailing Address 2
City St Zip MATTITUCK, NY 11952-0000
Property Address 1 10530 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9372
Tax Map No. section 122.00 block 2411 lot 15.000
Cross Street SOUND AVENUE & FACTORY AVENUE
Date Of Last Pump Out 1/00/78
•
Issue Date: 12/27/89 Judith T. Terry
Southold Town Clerk
,' (TOWN SEAL)
...
OFFICE OF THE TOWN CLERK ' •c�vFFO(,(
Town of Southold % C� = Application
Judith T. Terry, Town Clerk • s ..
`°M A �C ) $10.00 - Residential C/
Town Hall, 53095 Main Road ' . .
p. 0. Box 1179 cr3 ��" s{
��-=� �,.�, � $25.00 - Non-Residential
Southold, New York 11971 0 -CZ, O�'�����
Telephone _ 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / lJvl/i7
/2464DATE J
'OWNER NAME: 67t14
OWNER MAILING ADDRESS: CI ° 1816» ,//9y /0/l/6
OWNER PROPERTY ADDRESS. /#/3o_j2o1V1,/
Pg. ) Gi< •y / f
n
OWNER TELEPHONE NUMBER: ;9f.--
TAX
9fTAX MAP NO. : Section / Block Lot /j
CROSS STREET: ovie2 b%2y
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing 0/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / g
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.)
./4/84' - /
Signature of Applicant
RECEIVED BY:
Town Clerk's ffice
DATE: - — FS'p
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