HomeMy WebLinkAboutStephenson OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179 _
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 17 Residential X
Fee $ 10. 00 Non-Residential
Septic X Cesspool
NAME OF OWNER: Donald A. Stephenson
OWNER MAILING ADDRESS: P. O. Boli 196
Orient, New York 11957 . _
OWNER PROPERTY ADDRESS: Stephenson Road
Orient , New York 11957
OWNER TELEPHONE NUMBER: 516-323-2549
TAX MAP NO. : Section 17 Block 1 Lot 11 . 5
CROSS STREET: Main Road (Route 25)
TYPE OF SYSTEM: Septic Tank X New - Existing X
Cesspool New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 1986
Ju ith T. Terr
Southold Town Clerk
•
DATE: August 19 , 1986
(TOWN 'SEAL)-
OFFICE OF THE TOWN CLERKvFFO -'_ /�
Tow n of Southold ��� 4CQ Application No. /
Judith T. Terry, Town Clerk X4. i;
Town Hall, 53095 Main Road • 4,7-1 -_-4 Residential
P. O. Box 1179 crs ' Non-Residential
Southold, New York 11971
-17411-1.417
.
Telephone = 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. gi
Fee
$ /()
())00/1,---b fl ) DATE /3AZ
OWNER NAME: 3)i -, &,A)
OWNER MAILING ADDRESS: ,de /�‘
Q,
OWNER PROPERTY ADDRESS: , c'4./1/) --' P1=-4
Wil [= l�so�
OWNER TELEPHONE NUMBER: 3Z3
TAX MAP NO. : Section `2' cBlock f Lot // , L5
CROSS STREET: n'7 ate,
TYPE OF SYSTEM: Septic Tank ✓ New Existing
Cesspool New Existing
Residential Y Non-Residential
DATE OF PREVIOUS PUMP-OUT: Cr.,A6 ge(,
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.)
A I
Signature .' Applicant
RECEIVED BY:G41"1-cc
TownZks-67:;fircAe---)
DATE: y 19, 7I f
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