HomeMy WebLinkAboutTusa ma_/t'4u
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Town Hall, 53095 Main Road
ems® O 0 P.O. Box 1179
-__ 1, Southold, New York 11971
JUDITH T.TERRY ���� TELEPHONE FAX )7 765-1823
765-1801
TOWN CLERIC
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. 1176-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner TUSA, SAL
Mailing Address 1 6 MARLAN COURT
Mailing Address 2
City St Zip SMITHTOWN NY 11787-0000
Property Address 1 WILLIS CREEK DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-274-4314
Tax Map No. section 115.00 block 17 lot 17.015
Cross Street MEADOW BEACH LANE
Date Of Last Pump Out 0/00/00
Issue Date: 6/26/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 000Fo'( ��=
Town of Southold 0�® n. �e&-t- Application No. // 7,
Judith T. Terry, Town Clerk ,a I� 7.1 Residential
Town Hall, 53095 Main Road o ,(A, ,� -,.kx,, -
P. O. Box 1179 .--. ' �`, Non-Residential
Southold, New York 11971 %,-,, ,--:(z),0. ' `-,�
y � •
Telephone ®� ��® ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
/� 117
OWNER NAME: 2 L7:/..ril
OWNER MAILING ADDRESS: ' J C # Neb(J,r
,rencrii7 �A, 2,1, //717
OWNER PROPERTY ADDRESS: 4//bi , .s ege6A" _Die I/e-
/ii/y -i 7V MfN'
OWNER TELEPHONE NUMBER: 725/ 513/
TAX MAP NO. : Section ,1J`" Block 17 Lot /?. /J?
CROSS STREET: M-.',)OtA.., .1.9s(/if 4i9 Zi9die
TYPE OF SYSTEM: Septic Tank 1-"'-.... New L� Existing
Cesspool �� New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4
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.)
Nail ' f '
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
JUN . 6 1
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