HomeMy WebLinkAboutWorhle OFFICE OF THE TOWN CLERK • .t. OCK�' •
Town of Southold r_ OG
Judith T. Terry, Town Clerk ';"• r
Town Hall, 53095 Main Road '• a iv
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P. O. Box 1179 F�� r `,
Southold, New York 11971o =_ �-�•
Telephone
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(516) 765-1801 _
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 106 Residential X
Fee $ 10.00 Non-Residential
,Septic Cesspool XX
NAME OF OWNER: Marie Worhle
OWNER MAILING ADDRESS: 955 Lake Drive
Southold,New York 11971
OWNER PROPERTY ADDRESS: 955 Lake Drive
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-1898
TAX MAP NO. : Section 59 Block 5 Lot 16
CROSS STREET: Kenny Road
TYPE OF SYSTEM: Septic Tank New Existing,
Cesspool X New Existing x
• Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: None
Ju ith err
Southold Town erk
DATE: October 22, 1986
(TOWN SEAL) •
OFFICE OF THE TOWN CLERK �•c1FOCA-
Town of Southold �� CQ Application No./
Judith T. Terry, Town Clerk %►
Town Hall, 53095 Main Road o A514;4'. Residential
�`,
P. O. Box 1179 cry '> 9 ; Non-Residential
Southold, New York 11971 O ® }. •I•
Telephone _ .( t
•
(516) 765-1801
TOWN OF SOUTHOLD
RECEIVED
OCT 221986 SOUTHOLD WASTEWATER DISPOSAL DISTRICT
T wn Cterk Southold APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /04,
Fee $ /6)(-3'c
DATE VC7r .22 'l / (r)�
OWNER NAME: // 114/6" W®R;ffL(-
/
OWNER MAILING ADDRESS: % � I-4(/�6 J
.s17 UT/-14-D1 N. // V7 /
OWNER PROPERTY ADDRESS: , -,4 K
S® c',Y/t160Li, /V!/. 1/971
OWNER TELEPHONE NUMBER: j-76J / 9' 9
TAX MAP NO. : Section S.1 Block Lot
CROSS STREET: 14)C-/K Hy /2 6 .
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential X- Non-Residential
DATE OF PREVIOUS PUMP-OUT: /,/dig/C
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.)
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Signature of Applicant
RECEIVED BY: (g.,..„a r
Town Qjerk's Office
DATE: ,(2,(7ac7, /Fcr-
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