HomeMy WebLinkAboutSoullas Ar2A41 '=4
Z Town Hall, 53095 Main Road
ems® !"(2) ��. P.O. Box 1179
r �! Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK 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. 1289-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SOULLAS, ESTHER H.
Mailing Address 1 605 ZENA ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 605 ZENA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4720
Tax Map No. section 106.00 block 5 lot 16.000
Cross Street CAPTAIN KIDD DRIVE
Date Of Last Pump Out 0/00/82
Issue Date: 10/30/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c��FFO(,r�'= �
Town of Southold ® CQ ' Application No. i c)3�f1'
cy
Judith T. Terry, Town Clerk zt `a :
Town Hall, 53095 Main Road a ,= $10.00 - Residential
P. O. Box 1179 Ln V'•" F i $25.00 - Non-Residential
Southold, New York 11971 O "®
Telephone j `� •�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 14.1,01
—`1
DATE /o/if
OWNER NAME: 440 A. G,/
•
OWNER' MAILING ADDRESS: 6,6‹ -WA- gen
OWNER PROPERTY ADDRESS: Csait4e)
OWNER TELEPHONE NUMBER: AF .-471-U
TAX MAP NO. : Section (0 (Q ' Block Lot 1‘
CROSS STREET: (1/4.4244,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing J
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: c. 0
LOCATION MAP: Must be attached hereto bef re permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
• jadi / )
141,
Signatur--sof • pplicant
RECEIVED BY: . /�'_ /, ,
.AClerk's Office
DATE:
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