HomeMy WebLinkAboutO'Connor JUDITH T. TERRY Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK ( ) r=7,1
REGISTRAR OF VITAL STATISTICS ` :�` Southold, New York 11971
MARRIAGE OFFICERS X41, Fax (516) 765-1823
G �® Vii Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1964-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner O'CONNOR, DENNIS AND LINDA
Mailing Address 1 P. O. BOX 323
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 380 DEER DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5857
Tax Map No. section 114.00 block 10 lot 3.000
Cross Street WESTPHALIA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/27/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FOUr �
Town of Southold �® CQG Application No.
Judith T. Terry, Town Clerk . �„ " � $10.00 - Residential
Town Hall, 53095 Main Road• `
P. O. Box 1179 cry tk `'
�� $25.00 - Non-Residential
Southold, New York 11971 O � T" ��`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ -
DATE g Z
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OWNER NAME: b M ( 5 Ll i 3 Ni 612
OWNER MAILING ADDRESS: . 6' 130S. 3 2-3 '�'
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OWNEROWNER PROPERTY ADDRESS: 3e0 Deer
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OWNER TELEPHONE NUMBER: -9 56 5 7
TAX MAP NO. : Section I ( `T Block 1 0 Lot 3
CROSS STREET: LiEs 6P HAL (2D
TYPE ,OF.SYSTEM: - Septic Tank New Existing
Cesspool New Existing
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.)
Signature of Applicant
RECEIVED' BY: • - - -
Town Clerk's Office
DATE:
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