HomeMy WebLinkAboutO'Brien (2) OFFICE OF THE TOWN CLERK
Town of Southold , �� C�y
Judith T. Terry, Town Clerk '1,,
Town Hall, 53095 Main Road •
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P. O. Box 1179 � ` g•�
Southold, New York 11971 Q ® . •'
Telephone
(516) 765-1801 '
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 189 Residential X
Non-Residential
Fee $ 10.00 Septic Cesspool X
NAME' OF OWNER: Catherine C. and Thomas M. O'Brien
OWNER MAILING ADDRESS: Jennings Road
Southold. New York 11971
OWNER PROPERTY ADDRESS: Jennings Road
Southold_ New York 11971
OWNER TELEPHONE NUMBER: 516-765-1627
TAX MAP NO. : Section 54 Block 7 Lot 5
CROSS STREET: Booth Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: June 1976
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eT1.11)7"--
Southold Town C
DATE: January 6, 1987
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(TOWN ;SEAL)
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OFFICE OF THE TOWN CLERK �FFO
Town of Southold ��SCQ Application No./e/7
Judith T. Terry, Town Clerk . t L� .,.
Town Hall 53095 Main Road C �' , "ac Residential
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P. O. Box 1179 /7 �� , 4"�-`" ' Non-Residential
Southold, New York 11971 'O��•`�
Telephone _�.( sge
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL ' _ . ,
Operation Permit No.7(fY
Fee -
Y
'2
DATE let W
OWNER NAME: Cy vbk' .0 Q vv i s 111 . O}igi
OWNER MAILING ADDRESS: .1 EN 141146S Pomo
Sou'1io(-o1 1�1•`i. I I rzi
OWNER PROPERTY ADDRESS: (5w,4,E- / ooe)
OWNER TELEPHONE NUMBER: 7( 5" /0 .9
TAX MAP NO. : Section 5L--/- Block ' 7 Lot 3
CROSS STREET: f3oo �614NtaGS
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - ) New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: J vME 19.7
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.)
&evC)
Signature of Applicant
RECEIVED BY:
Town Cler 's Offi
DATE: /— c,2
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