HomeMy WebLinkAboutMoller (2) r no
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Town Hall, 53095 Main Road
&P ���` P.O. Box 1179
���� Southold, New York 11971
JUDITH T.TERRY ' ®/ �•• FAX(516)765-1823
TOWN CLERK %rail/0° 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. 1164-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOLLER, WILLIAM AND ADELE
Mailing Address 1 P. O. BOX 965
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 OLD COVE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7498
Tax Map No. section 111 .00 block 5 lot 3.000
Cross Street VANSTON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/20/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'COFO .�'
Town of Southold �� ? 4 Application No// /�(p
1
Judith T. Terry, Town Clerk �� � yt �,
Town Hall, 53095 Main Road
� � k � rC 7 $10.00 - Residential
p- 0. Box 1179 cn F ` ,' $25.00 - Non-Residential
� r " ,•
Southold, New York 11971 uO 0�,••�
Telephone -70 r
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE J //1/
OWNER NAME: /0///,44/ 1 / (7g o ,
tla �p� /)
OWNER .MAILING ADDRESS: � ,�� ,�,��(
� � � t. i
('T��e wee // 5
OWNER PROPERTY ADDRESS:
R 5.-.41/1/P--
OWNER TELEPHONE NUMBER: #7g9 —
TAX
9 —TAX MAP NO. : Section 07 Block � Lot 3
CROSS STREET: I,/ c• ' ' fr./
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
•1
Residential V Non-Residential
iz•
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.)
Signature of Applicant
RECEIVED BY:
t4 n Clerk's Office
DATE: JQ9m 2o OS
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r14'•' -. _ •- 1MSOSSID SEAL SHALL NOT ES CONSIDNEr ^ '�F •� ' `a•• __
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n(w ' '� MAMMIES INDICATED HEREON SHALL Rut. .
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