HomeMy WebLinkAboutMould Milir ',�� Town Hall
JUDITH T. TERRY �'� � � __ , 53095 Main Road
TOWN CLERK F1' P.O. BOX 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS •
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MARRIAGE OFFICER
0 Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1800-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOULD, JESSE A. AND RUTH M.
Mailing Address 1 VILLAGE LANE
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 VILLAGE LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2751
Tax Map No. section 25.00 block 1 lot 8.002
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 11/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
Town of Southold �� ; CQG?, Application No./70v
Judith T. Terry, Town Clerk r is; y
Town Hall, 53095 Main Road V. :1!-;, �`} $10.00 - Residential
P. O. Box 1179 u' _ '>04 $25.00 - Non-Residential
Southold, New York 11971 O �0N;�
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Telephone ''-ll .
(516) 765-1801 1 �:
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE //..F—q)/
OWNER NAME: IJGS.S(i R Guk q c.cIG) (i - (v\oL )
OWNER MAILING ADDRESS: V l9e. J-.ce.�c
c.E-crct N y. I cts-7
OWNER PROPERTY ADDRESS: 0.60,,Q.
OWNER
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OWNER TELEPHONE NUMBER: 3 ;23 —0275'/
TAX MAP NO. : Section 2`�j Block Lot 3
CROSS STREET: , a c s-
TYPE OF SYSTEM: Septic Tank I New Existing
Cesspool ( New Existing
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: y — 9/ e
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.)
tam/
S'gnature of Applica -t
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RECEIVED BY:
Town Clerk's Office
DATE: