HomeMy WebLinkAboutNugent Town Hall, 53095 Main Road,
�® ®� P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK 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. 1311-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NUGENT, DORIS K.
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Mailing Address 1 P. O. BOX 694
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Mailing Address 2
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City St Zip GREENPORT NY 11944-0000
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Property Address 1 57 SUNSET LANE
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Property Address 2
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City St Zip GREENPORT NY 11944-0000
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Owner Telephone No. 516-477-8816
Tax Map No. section 33.00 block 4 lot 58.000
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Cross Street SOUND DRIVE
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Date Of Last Pump Out 0/00/85
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Issue Date: 11/17/89 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK FF�
Town of Southold 0�� CQG Application No.
Judith T. Terry, Town Clerk - l
Town Hall, 53095 Main Road $10.00 - Residential
P. 0. Box 1179 cn $25.00 - Non-Residential
Southold, New York 11971 O ®
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No./3 0
Fee $
DATE
OWNER NAME: � (} p S /V
6 f
OWNER MAILING ADDRESS: BQ LR c l„ 9 1
�Q ee1,),Qe5 /,>-;
OWNER PROPERTY ADDRESS : 7 Sofyl5e /-7 �
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section _ Block Lot
CROSS STREET: _d"a4z/-cam
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: alal/.� �C '
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.)
6
F7�
g� Signature of Applicarff
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RECEIVED BY:
Town Clerk's Office
DATE: