HomeMy WebLinkAboutStrub rtli 1
Town Hall, 53095 Main Road
t:ily �` P.O. Box 1179
1N2Southold, New York 11971
NDITH T.TERRY i�yd FAX(516)765-1823
TELEPHONE(516)7654801
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. 1143-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STRUB, VERNON C.
Mailing Address 1 P. O. BOX 388
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2000 PARK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8359
Tax Map No. section 123.00 block 8 lot 7.000
Cross Street MARRATOOKA ROAD
Date Of Last Pump Out 9/12/75
Issue Date: 6/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
' OFFICE OF THE TOWN CLERK . - is "
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• Town of Southold - C� "• Application No. //�._'_
Judith T. Terry, Town Clerk . 4 y
Town Hall, 53095 Main Road I $10.00 - Residential
�,� <
P. O. Box 1179 U a 1 j
_�,w� •• $25.00 - Non-Residential
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Southold, New York 11971 O ' • � •
Telephone -_ 1 1% • �•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
• DATE ,.1UNvi= 7 t9 V9
'OWNER NAME: \i-r-R►.JoK+ C7 . St2,US�
OWNER MAILING ADDRESS: IpARv. nvr,NiJ .Q PO_ Rt,x -Bp
OWNER PROPERTY ADDRESS: 2,000 PRIX �`___
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OWNER TELEPHONE NUMBER: 5((, - -
TAX MAP NO. : Section I2.3 Block $ Lot 7
CROSS STREET: Vlnis2,2,a root-cA I?
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: i//Z/ 7S
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:
Town Clerk's Office
DATE:
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