HomeMy WebLinkAboutMonsell r'j Town Hall, 53095 Main Road
e; O Vit, P.O. Box 1179
- N2c00/ *P',./� Southold, New York 11971
JUDITH T.TERRY 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. 1144-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MONSELL, ALBERT K., JR.
Mailing Address 1 RR 1, BOX 142
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4045 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4275
Tax Map No. section 107.00 block 1 lot 9.000
Cross Street KNOLLWOOD LANE
Date Of Last Pump Out 0/00/00
Issue Date: 6/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
00,
OFFICE OF THE TOWN CLERK `��FFQU ,"
Town of Southold ®�® >x C��' Application No. iNK
Judith T. Terry, Town Clerk . _
Town Hall, 53095 Main Road I Residential
P. O. Box 1179 �'lAsNon-Residential
Southold, New York 11971 ® $
Telephone -_41/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
• for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ it)
DATE 6/blif
OWNER NAME: 4445 ever it' ('4 &&)-L Pt
OWNER MAILING ADDRESS: 't / fi
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OWNER PROPERTY ADDRESS: 1104/5- C Ai/A /IV&
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OWNER TELEPHONE NUMBER: ,/—yid- T ��
TAX MAP NO. : Section /0 '/ Block / Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool New Existing 4.--/
Residential V/ 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.)
Nig&
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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