HomeMy WebLinkAboutTheoharides fffff
$141 C5tfOLA 1)1 1.
"iG
JUDITH T. TERRY z Town Hall, 53095 Main Road
TOWN CLERK v T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971 •
Fax (516) 765-1823
MARRIAGE OFFICER �Q O� 1
=
fig
OFFICE OF THE TOWN CLERK (-(7
Judith
0
Town of Southold �o�y CQ Application No.
Judith T. Terry, Town Clerk '`- ►�'� ✓
Town Hall, 53095 Main Road j $10.00 - Residential
o �
P. O. Box 1179 cn Vii- t" �` $25.00 - Non-Residential
Southold, New York 11971 O '0_4W '.
Telephone
Ol 'itNe•
O
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE //23193
OWNER NAME: 4/1-/ 1-
OWNER MAILING ADDRESS: /D, 9C'X W/fie?/
ci7 /197/
OWNER PROPERTY ADDRESS: SO 3 A f'746:---- 5 VS=
‘,1771/-e,6� 4/ V //9
OWNER TELEPHONE NUMBER: ri-„ 76•5" -277/ ( 3)oT/- 273s)
TAX
MAP NO. : Section Block Lot
CROSS STREET: 4Q/ v/f7E D/ ( oc
TYPE OF, ,SYSTEM: Septic Tank New Existing
Cesspool ' New Existing
Residential i/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: ///If/C-4./a //(/l ,� i7e4/7". ,ZiEZ/ ��//
/te -
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.)
fi
11
Signature of Applicant \
RECEIVED.BY: j
Town Clerk's Office
DATE: -
free,r4/ (jaYr-r--
Usc I
Yki
m/.9 « �4�