HomeMy WebLinkAboutWallace �',0�S GAJ`
JUDITH T. TERRY • ` Town Hall, 53095 Main Road
TOWN CLERK
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T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS •6P S Southold, New York 11971
y 10. Fax (516) 765-1823
MARRIAGE OFFICER O AV.*
�y®� %Wr�i� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3010-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WALLACE, ROBERT
Mailing Address 1 P. O. BOX 213
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 295 SHIPYARD LANE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2565
Tax Map No. section 38.00 block 1 lot 3.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 4/29/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK S\FHU(
-�-
Town of Southold Application No. jOj
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road = ' "y-,. r $10,.00 - Residential
u
P. O. Box 1179 ' 1 ' .` $25.00 - Non-Residential
Southold, New York 11971 O `cb;. '
Telephone *01.
(516) 765-1801,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
___.__APPLICAT ION_____ .
__ - - -
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0,66
DATE 47://7,1?-3‘ '
OWNER NAME: P063 ee7 LA.) A�1-4ec
OWNER MAILING ADDRESS: p ® /3 a /3
AA ,/ //73Y
OWNER-PROPERTY ADDRESS: „2,945-
/0 s9 retedo
,2?S /0s9retedo 1` //y39
OWNER TELEPHONE NUMBER: X77- ' / 77- („15-Lg
TAX MAP NO. : Section Block Lot
CROSS STREET: rgo 07e- c9. $�
TYPE tOF SYSTEM: Septic-Tank" -New Existing
Cesspool New Existing
Residential - 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
RECEIVEDBY:
Town Clerk's Office
DATE. . -
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