HomeMy WebLinkAboutNYS Office of Parks & Rec Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY TELEPHONE
TOWN CLERK (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. 723-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NEW YORK STATE OFFICE OF PARKS
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Mailing Address 1 RECREATION & HISTORIC PRES.
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Mailing Address 2 MAIN ROAD
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City St Zip ORIENT NY 11957-0000
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Property Address 1 MAIN ROAD
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Property Address 2
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City St Zip ORIENT NY 11957-0000
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Owner Telephone No. 516-323-2440
Tax Map No. section 132. 00 block 1 lot 13 . 000
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Cross Street ORIENT STATE PARK
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Date Of Last Pump Out 0/00/00
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Issue Date: 6/01/88 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold �� �QG Application No.
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road Residential r/
P. 0. Box 1179 cr3 Non-Residential
Southold, New York 11971 4
Telephone OlAkY►���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for It
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /p op
DATE ✓ "��'8B ,
O W N E R N AM E: /y,Yf age,f-a �r �ccle�7b� f� tT�Tic �T�' •9�i8r1 ; ;.,,`'
OWNER MAILING ADDRESS: eewaf C6�4 "'gee
OWNER PROPERTY ADDRESS: S4417P 4r .941ye
OWNER TELEPHONE NUMBER/:
TAX MAP NO. : Section Block Lot
�Ty,X i.J� /�o� sf✓,¢i/,s�s� .
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing !#A&
Residential 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.)
ignatu're of Applicant
RECEIVED BY: Zle� "e�_
I Town Clerk's Office
RMVW
DATE:
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J U11 411988,,
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