HomeMy WebLinkAboutTerry (4) V.
Lin
Town Hall, 53095 Main Road
‘°e1,
. P.O.P.O. Box 1179
-__ 101 � ��' Southold, New York 11971
JUDITH T.TERRY TELEPHONE
TOWN CLERK (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. 737-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner TERRY, RENSSELAER G. JR.
Mailing Address 1 P.O. BOX 11
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 285 OAKLAWN AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3027
Tax Map No. section 61.00 block 3 lot 4. 000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/82
Issue Date: 6/23/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c•OFU( r�'- a
Town of Southold k,% , CQG' , Application No.7 (l
Judith T. Terry, Town Clerk .` : ': `
Residential
Town Hall, 53095 Main Road ta _
P. 0. Box 1179 (13 " ,;, a; : �; Non-Residential
Southold, New York 11971 O�Ol ' •'* *O.."
�0� ���
Telephone `"
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
1
DATE5)4"-b-41-' ZZ7,8S'
OWNER NAME:
4,??,A,k)//2.1aeli•, 7--e4A9t— .7).(to,
OWNER MAILING ADDRESS: Ao_ ( %
-� R9-, 1
OWNER PROPERTY ADDRESS: A7,5- Q,�, _
OWNER TELEPHONE NUMBER: 5 j Co - 7k) S" -'3b Z-7 c2®
TAX MAP NO. : Section � Block 3 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New New Existing
Residential, Non-Residential
DATE OF PREVIOUS PUMP-OUT: (e),.— 1
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.)
4107'607 .)- AA
Signature of A li t
RECEIVED BY:(% � Q
Town Clerk's' Off ce
DATE: • Q �� �f
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