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HomeMy WebLinkAboutSternett 5 Town Hall, 53095 Main Road, C) P.O. Box 1179 � 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. 1307-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner STERNETT, VICTOR LEO Mailing Address 1 76-66 AUSTIN STREET, APT. 5B Mailing Address 2 City St Zip FOREST HILLS NY 11375-0000 Property Address 1 735 GIN LANE Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 718-268-7320 Tax Map No. section 88.00 block 4 lot 7.000 Cross Street MIDWAY Date Of Last Pump Out 0/00/00 Issue Date: 11/14/89 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK yvFFX�'` Town of Southold � C� Application No. 7 0-7 Judith T. Terry, Town Clerk � �S'f;; Town Hall, 53095 Main Road R $10.00 - Residential p. O. Box 1179 cry *- ;r'.r } 'moi ; $25.00 - Non-Residential Southold, New York 11971 Oy Telephone -5Pj ark (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ (0( ©0 • DATE OWNER NAME: GTO L (E ri OWNER MAILING ADDRESS: —16 -66 -) USTiAl STRA, PT( 3-(3 +\-1U-S, N, (('3 OWNER -PROPERTY ADDRESSi f: S ' (\/ L/4 I .�- pro_ 1 o 29 Ste+ 07-f 1 V L!' r\f,yr OWNER TELEPHONE NUMBER: (7 q) _ /(g--`?'3 .O : C��( (p) i6f" 3S3). TAX MAP NO. : Section 1Z-14-TS Block /7/ Lot 7 CROSS STREET: G i V -(,,C} JEJEi k ( b A( TYPE OF SYSTEM: Septic Tank New Existing Cesspool / New Existing I/ Residential V Non-Residential DATE OF PREVIOUS PUMP-OUT: itiEVek. (ovJt� kIe f1Akrtz,J i0 BE,-I autLl-FALL itiG I . owNre pvzc.ilf- J sc't�r,\/Cc' (q4z. 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.) C K Signatu e of 'applicant RECEIVED BY: /d` Town Clerk's 0 ice DATE: // — �-- r I. 0 c61f0 poo f S i I .p-o 0 S- a I UL 1 1