HomeMy WebLinkAboutVan Ryswyk loft
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Town Hall, 53095 Main Road
t. Q ®� P.O. Box 1179
--_'��® ���,� Southold, New York 11971
JUDITH T.TERRY ��ir���' 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. 1506-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VAN RYSWYK, JOHN AND LORRAINE
Mailing Address 1 780 LEGION AVENUE
Mailing Address 2
City St Zip MATTITUCK Y 11952-0000
Property Address 1 780 LEGION AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8324
Tax Map No. section 142.00 block 2 lot 13.001
Cross Street PACIFIC STREET
Date Of Last Pump Out 0/00/00
Issue Date: 7/25/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/
OFFICE OF THE TOWN CLERK c�vFFOL
Town of Southold %� - ��CD Application No. /5-0P
%Judith T. Terry, Town Clerk s ' i'� G
Town Hall, 53095 Main Road „� $10.00 - Residential
P. O. Box 1179Y` z.y�. .
� .�;� � s,{i':�„� �� $25.00 - Non-Residential
Southold, New York 11971 Obi-® � • O`���`
Telephone :�l •4 sit '� •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT '
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ l G • ill
DATE 7 - / f - ' 6)
OWNER NAME: d A ,v d ZdFI”17 /4,'m V19-,e/ ey ,S t-r/ `�
•
OWNER MAILING ADDRESS: 76 v Lg�} , a ,. /9 -
/9- 97, `7 f-r. c, /f/• - 7.7,,S-,?.
OWNER PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: .5/4 - o? Jct'- ef 3 7
y TAX MAP NO. : Section /1-7 . - Block a Lot /3.
CROSS STREET: s o
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1// New Existing
Residential t- Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4, !_, . i,- 11�'A e _ .�.1 /
� i
LOCATION MAP: Must be attached hereto bef a permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
__AL 0
r'il •i �• ,
Signature of Applic/ t /
RECEIVED BY:
Town Clerk's Office
DATE:
4 VS
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