HomeMy WebLinkAboutNine OFFICE OF THE TOWN CLERK ic.OfO(/fr`,OG
Town of Southold
Judith T. Terry, Town Clerk � K3_ y
Town Hall, 53095 Main Road 8 _
P. O. Box 1179 - ,�,
Southold, New York 11971
Telephone
(516) 765-1801 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 174 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Gladys M. Nine
OWNER MAILING ADDRESS: Box 171
Mattituck. New York 11952
OWNER PROPERTY ADDRESS: Love Lane
Mattituck. New York
OWNER TELEPHONE NUMBER: 516-298-4094
TAX MAP NO. : Section 140 Block 1 Lot 20
CROSS STREET: County Road 48
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: October 1986
•
Judith T. Terry
Southold Town Clerk
DATE: December 11 , 1986
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK S�FFO1,r '•
Town of Southold 0&� 40 " Application No. /7V
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road Residential
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P. O. Box 1179 v' ` _ Non-Residential
Southold, New York 11971 '�l�'. h �o���`
Telephone = ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /7'7
Fee $ J a 0
DATE AO 2-e. , j s' c,
OWNER NAME: 8RAA ()Alt
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OWNER MAILING ADDRESS: q . 1 7 / / I I
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OWNER PROPERTY ADDRESS: '
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OWNER TELEPHONE NUMBER: a r ® G "/
TAX MAP NO. : Section 1 1_4 0 Block l Lot
CROSS STREET: C\' L) 8-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ?i'--
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.)
Signure of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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