HomeMy WebLinkAboutWells abere
1
Town Hall, 53095 Main Road
• P.O. Box 1179
00,0'°� 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. 1171-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WELLS, RUSSELL C.
Mailing Address 1 115B GRAND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11935-0000
Property Address 1 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11935-0000
Owner Telephone No. 516-298-4457
Tax Map No. section 107.00 block 8 lot 41 .000
Cross Street WEST VIEW DRIVE
Date Of Last Pump Out 7/00/86
Issue Date: 6/26/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•; •
OFFICE OF THE TOWN CLERK ®CJ��`�OU,e
=
Town of Southold Q ' Application No. /777
Judith T. Terry, Town Clerk � z.
Town Hall, 53095 Main Road s. ` � . .. $10.00 - Residential
P. O. Box 1179 r }** ' i z $25.00 - Non-Residential
Southold, New York 11971 O ® h0��•
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: f ( J5F. 1( (1. Lt/ 6l f •
OWNER MAILING ADDRESS: Ns- 6 CRAW ,4L-E
c i v e lei 1,4,Y. 111'1
OWNER PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: ”7- Pif S-7
TAX MAP NO. : Section i 0 7 Block Lot C-14 if
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: iro
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.)
a �
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
WORM
DATE:
AN 2 6 IStii
7 CIS Be
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