HomeMy WebLinkAboutVan Wart OFFICE OF THE TOWN CLERK Lam '
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Town of Southold
Judith T. Terry, Town Clerkaft-Ea
Town Hall, 53095 Main Road
P. 0. Box 1179c� 1 •
Southold, New York 11971 � _ O�
Telephone 71( xit
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 548 Residential x
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Laurence E. and Eileen Van Wart
OWNER MAILING ADDRESS: RR 3, 295 Bennetts Lane
Southold, New York 11971
OWNER PROPERTY ADDRESS: 295 Bennetts Lane
Southold, New York 11971
OWNER TELEPHONE NUMBER: 516-765-2303
TAX MAP NO. : Section 70 Block 9 Lot 19'
CROSS STREET: Custer Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. T rry .
'Southold Town Clerk
DATE: December 24. 1987
•
(TOWN SEAL)
OFFICE ;OF THE TOWN CLERK cCF�(A'�'= �YK
Town of Southold �� > CQG' Application No.
Judith T. Terry, Town ClerkS '�
Town Hall, 53095 Main Road r, "; "` 4%, I Residential -
P. O. Box 1179 u" i ; Non-Residential
Southold, New York 11971 O "6;t4.0*
Telephone •
: 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. (5-44,
Fee $ /
DATE /.21Q�-/E
OWNER NAME: L,4e/r-2./vc-E Eiu'd •Ea I VA LOA- c`r
OWNER MAILING ADDRESS: f3-e.iNe QC's
`amu%-,1(AA) Pi i19 -7 i
OWNER PROPERTY ADDRESS: Spiry, 2
OWNER TELEPHONE NUMBER: "76,&-- R303
1 7v9 / 7
TAX MAP NO. : Section ) Block Lot
.33 B„
CROSS STREET: C u S c e c- iqv e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing '\
Residential K Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Signature of Applicant
RECEIVED BY: -c-cc- �
Town erk's Office
DATE: EC 241SU
Town Clerk MOM
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