HomeMy WebLinkAboutMellas (2) pte_tf T=
Town Hall, 53095 Main Road
�® O i!$ P.O. Box 1179
_ � ®i�� Southold, New York 11971
JUDITH T.TERRY '%- 4� FAX(516)765-1823
"����� TELEPHONE(516)765-1801
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. 1185-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner MELLAS, JAMES P.
Mailing Address 1 P. O. BOX 267
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 ORCHARD STREET
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 25.00 block 5 lot 3.000
Cross Street TABOR ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/29/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•'
-
OFFICE OF THE TOWN CLERK • CQ c0FotA-,-
Town of Southold ® ' Application No. // 3
Judith T. Terry, Town Clerk a�{f ' G
= U C $10.00 - Residential
Town Hall, 53095 Main Road � �� ���=..
P. O. Box 1179 u' �''�' i
� 'cat,� ��,-yam,. $25.00 - Non-Residential
Southold, New York 11971 ® `®
Telephone ®lw., �1���'��•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 9 /i / P
OWNER NAME: J4,1";‘Z L/ C �!��= •
OWNER MAILING ADDRESS: (Pp- /Z)oX e::.?‘ 7
D7a/64if
OWNER PROPERTY ADDRESS: 4/11E
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section 0;§- Block 5 Lot eJ
CROSS STREET: /A �d2 1/"1
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
AP
Signature of AWwant
RECEIVED BY: At/ X--4- --1-1_12.
Town Clerk's Office
DATE: 7// Yg-7
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___ ..- { STATEMENT OF INTENT _
1 - THE WATER SUPPLY AND SEWAGE'D4SPOSAL
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49%2 D12CH/LfC� �CZF_ET $YSTEiVIS" FOR THIS RESIDENCE WILL
1E15.00 )t_ CONFORM' TO THE STANDARDS OF g�S E•.
y _ t SUFFOLK CO. DEPT. OF HEALTH SERVICES:
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APPLICANT..., '
Y5 SUFFOLK :COUNTY ",DEPT. OF HEALTH
ifl d- . I' , _S E R,V I C E's== FOR APPROVAL O F
OC ; \
CONSTRUCTION ONLY
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