HomeMy WebLinkAboutSullivan (4) lam_fre.r�„.
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�, Town Hall, 53095 Main Road
�® 1__” ` zr,ii`' P.O. Box 1179
'_ j�� _ ���i� 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. 1007-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SULLIVAN, RAYMOND J.
Mailing Address 1 SULLIVAN, VALERIE G.
Mailing Address 2 3150 BOISSEAU AVENUE, RT 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 3150 BOISSEAU AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4757
Tax Map No. section 55.,x.00 block 6 lot 1 .000
Cross Street YENNECOTT DRIVE
Date Of Last Pump Out 0/00/83
Issue Date: 2/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ` S\FFD(A' -
Town of Southold Application No./z),()
Judith T. Terry, Town Clerk . ' J►
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Town Hall, 53095 Main Road � g= Residential /
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P. O. Box 1179 T ;yi ;' Non-Residential
Southold, New York 11971 ' OO �0*�`
Telephone : 1 Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
o
Fee $ /'t1
DATE --/7/ -,7
OWNER NAME: R4)N.o ALP .! . `f rlf-1,6 ,1 G, S IJ L L/1/fI'/V
OWNER MAILING ADDRESS: 3 j,-0 1361S2E/4U AVE, R[
S2 v-Tl-f-a Z-7> j Y // 9 7/
OWNER PROPERTY ADDRESS: ?AS-0 80/SS'E4 LI A- VE
c —, OLp,, / Y // 77 (
OWNER TELEPHONE NUMBER: 7 s-- 473- 7
TAX MAP NO. : Section .',� Block 6 Lot /
CROSS STREET: YEW ME Co Z'-T' 1)/Z' tie
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing t/
Residential 0� Non-Residential
DATE OF PREVIOUS PUMP-OUT: z‘--/ ✓ era
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.)
g�ure`of Applicant
RECEIVED BY: 441111k ,j '�t
own rCI:rk's Office
DATE:
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