HomeMy WebLinkAboutVan dover '
'11 i) i Town Hall, 53095 Main Road
\s em® O ®� P.O. Box 1179
1�� ® s2 �` Southold, New York 11971
JUDITH T.TERRY 1��. 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. 3598-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VAN DOVER, TILLIE
Mailing Address 1 1360 BROADWATERS ROAD
Mailing Address 2 BOX 92B
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1360 BROADWATERS ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5240
Tax Map No. section 104.00 block 9 lot 5.000
Cross Street VANSTON ROAD
Issue Date: 3/11/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cvFF[1(��'= .-
Town of S �uthold Q C' Application3 /6
� Oc* ":;�• No. �
Judith T. Tern Town Clerk �� ' z7 .0\
Town Hall, 53095 Main Road ,. , , ,_t $10.00 - Residential
P. O. Box 1179 t'] �' : *" ' iii
vel;
4 ,� ,��. � $25.00 - Non-Residential
Southold, New York 11971
Telephone
-46:1
(516)
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD 'WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 3 //f / 9
OWNER NAME:
OWNER MAILING ADDRESS: /33 d I. WIt, C ,d tt
OWNER PROPERTY ADDRESS : XIII 1 ztCa 6,,,eli AMA leader)q /1 fr
OWNER TELEPHONE NUMBER: , /.' ` //f ?1 Sold
TAX MAP NO. : Section i 3 ,1 7 Block �aA� �� Lot clrd-
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ( New Existing
Residential V Non-Residential
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.)
eahei trArl-a/
Signature of Applicant
RECEIVED BY:
� '
own Clerk's Office
DATE: 3 / 1 /77
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