HomeMy WebLinkAboutMichel OFFICE OF THE TOWN CLERK ;
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OFFICE OF THE TOWN CLERK ' ��F%rCQ
Town of Southold �� _: Application NO.3Z �--
Judith T. Terry, Town Clerk ;�' ra
Town Hall, 53095 Main Road ~"„ Residential
P. O. Box 1179 t r Non-Residential
Southold, New York 11971 O ® �•`
Telephone o.( y ��� ,•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE " ` V d
OWNER NAME: (#/ e5 (Nr ,i,ckeL
OWNER MAILING ADDRESS: /c.
3u nov (/g7/
OWNER PROPERTY ADDRESS: / O/9/60.1or02 C a&- / /i('
eo z_D /lJ ///-2,
OWNER TELEPHONE NUMBER: 5/G ) f SZ‘ /
TAX MAP NO. : Section qv Block Lot /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - New Existing )4-
Residential
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Ptcemi 1984
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.)
A 60
igna ure of Applicant
eu/, r(e5 M4ee
RECEIVED BY: F ,v ' • 4.
Town Clzik's Office
DATE:
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