HomeMy WebLinkAboutWeiss OFFICE OF THE TOWN CLERK . FU
Town of Southold , QO��F ()Uri;
Judith T. Terry, Town Clerk ; J'
Town Hall, 53095 Main Road
P. O. Box 1179 -W �
Southold, New York 11971 Q $
Telephone o,( * •
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 119 Residential
Non-Residential
Fee $ 10.00
Septic x Cesspool x
NAME OF OWNER: Alan J. Weiss
OWNER MAILING ADDRESS: 2010 Pequash Avenue
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: 2010 Pequash Avenue
butchogue, New York
OWNER TELEPHONE NUMBER: 516-734-5216
TAX MAP NO. : Section 103 Block 11 Lot 17
CROSS STREET: Old Pasture Road
TYPE OF SYSTEM: Septic Tank X New Existing x
Cesspool X New Existing 'X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Before 1975
Judith T. Term
Southold Town Clerk
DATE: Novemherr3, 1986
(TOWN SEAL)
, •• ...
OFFICE OF THE TOWN CLERK �clVFFDi',,(� '-
Town of Southold �� _ CQG' , Application No. /f
Judith T. Terry, Town Clerk �` 4,* �
Town Hall, 53095 Main Road - ;i; ' Residential
P. O. Box 1179 ;
cn � ;4 Non-Residential
Southold, New -York 11971 0.O �`
0 = S
Telephone 1 �OI.
(516) 765-1801
RKEWID TOWN OF SOUTHOLD
t[fV 0 31'
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Um Cle*k Southold
APPLICATION
for.
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
chi _
Fee $ A Q
DATE //-3 (f-6
OWNER NAME:
/ / -
OWNER MAILING ADDRESS: ` /p '/'O /,���i az-e-
OWNER PROPERTY ADDRESS: AO/?>
OWNER TELEPHONE NUMBER: -2,31/ S /
TAX MAP NO. : Section f 6,3 Block / 1 Lot /7-
CROSS STREET: ®LD /-7/3-51-‘44"6P 04a
TYPE OF SYSTEM: Septic Tank New Existing ✓
Cesspool ✓ New Existing
Residential - Non-Residential
DATE OF PREVIOUS PUMP-OUT: Ifs
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.)
//
Signa of Applicant
RECEIVED BY: C5 c
Town C rk's Offce
DATE: 3_ / X
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