HomeMy WebLinkAboutVerity (2) 400,-af(lire
1174. Town Hall, 53095 Main Road
P.O. Box 1179
�42 si �1,' Southold, New York 11971
JUDITH T.TERRY `=-.., %%''� 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. 1460-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VERITY, MARY JO
Mailing Address 1 30485 MAIN ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 30485 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5459
Tax Map No. section 102.00 block 2 lot 20.000
Cross Street STILLWATER AVENUE
Date Of Last Pump Out 0/00/85
Issue Date: 5/15/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �
�FFO =
Town of Southold s . :. �Ol Application No. ����
Judith T. Terry, Town Clerk ; 4f
Town Hall, 53095 Main Road :- $10.00 - Residential
P. O. Box 1179 cn fi•.r= :�°:Y� tri
� �-� T�•=� ,�� � $25.00 - Non-Residential
Southold, New York 11971 • O '®' '`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 1
•
DATE )P1641 ( 5- - q6
OWNER NAME: c,R� v (kik 112/
OWNER MAILING ADDRESS: 30 , Ct. /
/1J7 5 -
OWNER PROPERTY ADDRESS: Q
OWNER-TELEPHONE NUMBER: 73 V-
TAX MAP NO. : Section 1 D 2 ' Block Lot •
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool %‘),1_, New Existing
Residential d Non-Residential
DATE OF PREVIOUS PUMP-OUT: w CiA0caa
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.)
Sign re of Appl cant
RECEIVED BY:
Town Clerk's Office
DATE:
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