HomeMy WebLinkAboutVan Cleef OFFICE OF THE TOWN CLERK $ FO '
Town of' Southold O��FC�G _ -
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 1 `
P., 0. Box 1179 C` n tt��r= " "
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Southold, New York 11971 O
Telephone SQL
(516) 765-1801 m
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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OPERATION PERMIT _
SEPTIC TANK or CESSPOOL
Operation Permit No. 432 Residential X
. Non-Residential
Fee $ 10.00
Septic Cesspool X
- NAME OF OWNER: Clifford J. Van Cleef
OWNER MAILING ADDRESS: P.O. Box 111
Orient, New York 11957
OWNER PROPERTY ADDRESS: 25745 Main Road
Orient, New York
OWNER TELEPHONE NUMBER: 516-323-3551
TAX MAP NO. : Section 17 Block 4 Lot 3
CROSS STREET: Minn Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Approx. 1983 •
Southold Town Clerk
DATE: September 18, 1987
1 � '
(TOWN ;SEAL)
OFFICE OF THE TOWN CLERK cOFOC,r� 2
Town of Southold 0�� CQG Application No. c7 °Z
Judith T. Terry, Town Clerk
Town Hall 53095 Main Road +moi, '" .F : Residential
P. O. Box 1179 *.z Non-Residential
Southold, New York 11971 ‘;;;5 (llio
Telephonert
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 7 / 71cf\-
OWNER NAME: CL l r=FO, 6 J /
OWNER MAILING ADDRESS: 2,5-77,4 ,r /L) A- /.// iC�c7 4,0 a e"s
/V.1 //47. -7
OWNER PROPERTY ADDRESS: J',4 ,t
OWNER TELEPHONE NUMBER: Cr; ,' 3 2_- — 3r--7
TAX MAP NO. : Section / 7 Block ` Lot L3
CROSS STREET: /hi L 4 ue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing v
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: '11
LOCATION MAP: Must be attached hereto befor permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
et-
Signa t re of Applicant
RECEIVED B "r1.10:4A. ,. ,!,�
own% Jerk's ftfice
DATE: SEP 1719B
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