HomeMy WebLinkAboutWorrell .411 Se 01,XtbA
� � Town Hall, 53095 Main Road
�® �� P.O. Box 1179
l 411 .��e" Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-5-
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. 1193-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WORRELL, ROBERT
Mailing Address 1 514 BAILEY AVENUE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 514 BAILEY AVENUE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1941
Tax Map No. section 34.00 block 4 lot 11 .000
Cross Street KNAPP PLACE
Date Of Last Pump Out 0/00/00
Issue Date: 7/26/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
. IIS •
OFFICE OF THE TOWN CLERK
down of Southold � „� . V Application, No. l/-3
Jud.th T. Terry, Town Clerk ; ay
Town Hall, 53095 Main Road " - '_,,,x15,4 _.0 $10.00 - Residential ,}<
p. O. Box 1179 y ® &'$ �� $25.00 - Non-Residential
Southold, New York 11971 O ' O
Telephone o(_ `A\ 's�`
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. ,J/9
G
Fee $ /b G9
• DATE 009
'OWNER NAME: b�`21 (J evz. 2c 1/ •
•
OWNER MAILING ADDRESS: %f) 41 G,•Le-
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER: g22—)%1://
TAX MAP NO. : Section Lif Block y Lot ) 0
CROSS STREET: g 9 /6.]AA L
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: tc� °C.J6-1,i
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.)
L i
Signature of Applicant
RECEIVED BY:G .,-;._ac• - 4
Tow /Clerk' Office
DATE: MEMrazzza
JUL 2 6 1588
Tom CM Southold
ton toxArei
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