HomeMy WebLinkAboutStype JUDITH T. TERRY � Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICERFax (516) 765-1823
Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1791-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STYPE, ANDREW
Mailing Address 1 CRITTENS LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 CRITTENS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2889
Tax Map No. section 70.00 block 12 lot 9.002
Cross Street PARKWAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/fC=, , '..- " • iii�'
OFt i E O, THE TOWN CLERK COFOCk
Town of Southold &„.% CQ • Application No. fl
Judith T. Terry, Town Clerk • � 4
Town Hall, 53095 Main Road �; $10.00 - Residential
p. O: Box 1179 � � �`' $25.00 - Non-Residential
Southold, New York 11971 O ••`
Telephone ..kw
es
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ it' , 0
DATE (0/0/9(
OWNER NAME: dr �l y
OWNER MAILING ADDRESS: (y {/e-st (,/d04 f
U0/f0 t /1/.. //f41j
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7 CK—.
TAX MAP NO. : Section < 2 0 Block /0N Lot / f,
CROSS STREET: /gaK/(lV , /P,
TY-PE OF SYSTEM: Septic Tank" " (Z.` New Existing
Cesspool (,,/ New Existing ' K
Residential (/ Non-Residential
DATE OF PREVIOUS PUMP-OUT:, OGi,7
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
4fre_
icant
RECEIVED BY:
Town Clerk's Office
DATE: ' -
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