HomeMy WebLinkAboutWyche _-
4 Town Hall, 53095 Main Road
ems® L) P.O. Box 1179
••� 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. 1018-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WYCHE, WILLIAM AND FANNIE
Mailing Address 1 BOX 14. RT 2. HOBSON DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 HOBSON DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8851
Tax Map No. section 122.00 block 6 lot 25.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/14/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK mc31FOUr .
Town of Southold �� CQ ' Application No.. I O h?
Judith T. Terry, Town Clerk -- � 3
Town Hall, 53095 Main Road (` 4 Residential
P. O. Box 1179 kgtA `' Non-Residential
Southold, New York 11971 O � �0/�`
Telephone : .� Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / 0000
DATE
OWNER NAME: .) f � ; CQ
°
OWNER MAILING ADDRESS: fi_01 , I
J14Je
OWNER PROPERTY ADDRESS:______
OWNER TELEPHONE NUMBER: 5 1 4 c/c 5-7
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool �� New Existing
Residential N•n-Residential
DATE OF PREVIOUS PUMP-OUT: • f-1 LM I clisr
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.)
tki I
i
Signature of A plicant
RECEIVED BY:
Town Clerk's Office
DATE:
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