HomeMy WebLinkAboutTyrer AO °Ai
Town Hall, 53095 Main Road
VOA, ®r P.O. Box 1179
k ' 4' Southold, New York 11971
JUDITH T.TERRY -% a/%%' FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1328-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TYRER, CLIVE & JOAN
Mailing Address 1 BOX 824
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 220 PRIVATE ROAD #3
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3057
Tax Map No. section 70 block 6 lot 38
Cross Street OAKLAWN 8 PINE NECK RD.
Date Of Last Pump Out 0/00/00
Issue Date: 12/01/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE oOF THE TOWN MIRK - .--IU FO ,„
Town of Southold ��`•_. �C�G_ Application No. i._. ',".21`.8"
Judith T. Terry, Town Clerk 1a. Kms, y - Z/
Town Hall, 53095 Main Road ' rs } $10.00 Residential
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P. O. Box 1179 U7 nb�,.y. w-�,,�.,;,n. \
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; � $25.00 - Non-Residential
Southold, New York 11971
Telephone �,(y,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE �-5, f 7
• 'OWNER NAME: €) d J •'
p ,L /
OWNER MAILING ADDRESS: e 1 i
a 0 T
OWNER_PROPERTY ADDRFS5:_ _� 2-� 1 -1 1 //,9�C 2G I
OWNER TELEPHONE NUMBER: 76 S - 3 t 9
• TAX MAP NO. : Section 1 fl Block 6 Lot 3
CROSS STREET: d A ' �,/ ,,L)(1/
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X( New Existing x
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: zirt,,,-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.)
ignature of plicant
RECEIVED BY: •
Town Clerk's Office
DATE: