HomeMy WebLinkAboutVerme OFFICE OF THE TOWN CLERK • qge(}{t+�
Town of Southold
Judith T. Terry, Town Clerk L� �-. p
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Town Hall, 53095 Main Road 4 . : "y
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P. O. Box 1179 c '.t,, ••
Southold, New York 11971.
- Telephone ;I.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD -WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 541 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Mary Verme
OWNER MAILING ADDRESS: 56 Tanyard Lane
Huntington, New York 11743
OWNER PROPERTY ADDRESS: Main Road
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-549-5865
TAX MAP NO. : Section 140 Block 3 Lot 27
CROSS STREET: Pike Street
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
•
Judith T. Terry
Southold Town Clerk
DATE: December 1c, 1987
•
(TOWN SEAL)
I I��
OFFICE OF THE TOWN CLERK
Town of Southold et .,t CQG Application No. _S/
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road '� tee, r< - Residential
P. O. Box 1179 u' T Non-Residential
Southold, New York 11971 O�w-® 44.7r-
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Telephone .( 4 0-
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE i. r /
OWNER NAME: /Z-C/
OWNER MAILING ADDRESS: (ir9 4? LaQ
OWNER PROPERTY ADDRESS: M & I r PcP n9 1 .7"— c<
OWNER TELEPHONE NUMBER: 1S---
TAX
S_TAX MAP NO. : Section 1 , () Block Lot 42.-
CROSS STREET: P
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool (/ New Existing (/
Residential ( � Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 9
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: o 1,_. _ •, L1
REcElvapwn %Ierk's 4 ffice
DATE: DEC 1 " 7
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