HomeMy WebLinkAboutNesbitt 1 -7o I/Ira, .
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® ,- .� Town Hall, 53095 Main Road
s',` P.O. Box 1179
����� ��(1. ,r,..•;!' Southold, New York 11971
JUDITH T.TERRY �s' .,,�i'!` FAX(516)765-1823
TOWN CLERK
%. viii' 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. 1417-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NESBITT, T. AND KRUMENACKER,E.
Mailing Address 1 P. O. BOX 98
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 105 BLUE MARLIN DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1148
Tax Map No. section 56.00 block 7 lot 10.000
Cross Street DOLPHIN DRIVE
Date Of Last Pump Out 0/00100
Issue Date: 3/15/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �
Town of Southold 0� . V ";
, Application No./4/77
Judith T. Terry, Town Clerk
Town Hall, 53095 plain Road fe, $10.00 - Residential
P. O. Box 1179 cr3 t-0114. „, $25.00 - Non-Residential
Southold, New York 11971 G' ' y ?'` '���`
Telephone �� `��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ✓D oc?
•
DATE
OWNER NAME: ', \\ S 6I It 04,4 , eA-k
OWNER MAILING ADDRESS: TC ®›cetc.1(
Sot o cQ) iL).-, Lt
OWNER PROPERTY ADDRESS: \O5 -13\ v'e Vt\a2r-lC r �r-
ScoLia-koLeP, �.`( ► 911
OWNER TELEPHONE NUMBER: �(oS�ll '{ �
TAX MAP NO. : Section 05-1", Block 7 Lot /0
CROSS STREET: �6_Ph,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ✓
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 421./...21S7
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: , moo
Town Clerk's ffice
DATE:
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