HomeMy WebLinkAboutO'Brien ,11''1[`1® e77.
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Town Hall, 53095 Main Road
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_y®i ,'e P.O. Box 1179
�� Southold, New York 11971
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JUDITH T.TERRY FAX FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1181-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner O'BRIEN, ANNE S.
Mailing Address 1 821 FRONT STREET
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 821 FRONT STREET
Property Address 2
City St Zip GREENPORTT NY 11944-0000
Owner Telephone No. 516-477-1241
Tax Map No. section 48.00 block 1 lot 3.000
Cross Street NINTH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 7/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �COF�(ir _
Town of Southold �® ..CSG' Application No. /g1
Judith T. Terry, Town Clerk �G
Town Hall, 53095 Main Road >r, Residential
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P. O. Box 1179 Cr) .- ` ' ► �' Non-Residential
Southold, New York 11971 O ® '` $
Telephone :®� Wit` •No , •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ [67
DATE us7- �+, / y'/4
OWNER NAME: ,4v,&-- 5 fig/_/A7
OWNER MAILING ADDRESS: &''0z/
OWNER PROPERTY ADDRESS: ,,,Zene/
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block Lot
CROSS STREET: 97e ,,4 /00A/7-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool r/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ic2-6(6.ties /?FS--
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:
Town Clerk's Office
DATE:
JUL ®
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