HomeMy WebLinkAboutMuir 14' c\VFOLke,
Town Hall, 53095 Main Road
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�® P.O. Box 1179
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��� Southold, New York 11971
JUDITH T.TERRY ® ���' TELEPHONE
TOWN CLERK (S1 G) 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. 679-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner MUIR, ROBERT
Mailing Address 1 BOX 126
City St Zip MATTITUCK NY 11952-0000
Property Address 1 GRAND AVENUE
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8475
Tax Map No. section 107. 00 block 1 lot 22. 000
Cross Street KNOLLWOOD LANE
Date Of Last Pump Out 0/00/56
Issue Date: 4/28/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III
OFFICE OF THE TOWN CLERK ��FOU(I
Town of SoutholdA' Application No.62 7
Judith T. Terry, Town Clerk
.
Town Hall, 53095 Main Road ® ,.. 1 Residential
P. O. Box 1179 cra � Wu Non-Residential
Southold, New York 11971
Telephone _ Y
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
de,Fee $ /0
DATE f/ 7,�,9"
OWNER NAME: ®v7-4t /%r/;?
OWNER MAILING ADDRESS: x /�,� /;tri//44/
OWNER PROPERTY ADDRESS: LoviCn ,/,��/�d �,,� 4-e141d•1(tvdod 24'4.0
/,7r/V- 4' /1/.
OWNER TELEPHONE NUMBER: ? - yj�'"
TAX MAP NO. : Section //,7 Block „�
/ / Lot
CROSS STREET: (44/704. G� 6--/.1,4,-if r! 11/r. '1?
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: //_34.
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.)
Af >-
Signature of Applicant
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RECEIVED BY :0' r „
To n
/erk's Offi e
DATE: 11/671--
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