HomeMy WebLinkAboutYoung (3) Atnize.;
Town Hall, 53095 Main Road
P.O. Box 1179
6P:/ � „,4 ,?' Southold, New York 11971
JUDITH T.TERRY � FAX(516)765-1823
' �� TELEPHONE(516)765-1801
TOWN CLERK
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. 1355-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner YOUNG, MARJORIE M.
Mailing Address 1 P. O. BOX 855
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 530 BRAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4214
Tax Map No. section 126.00 block 1 lot 20.000
Cross Street ROUTE 25
Date Of Last Pump Out 7/08/81
Issue Date: 1/10/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
♦ / �.. .
OFFICE OF THE TOWN CLERK _ ,...:01.4,
c�vFFO(,(��'- �I
Thwn of Southold �-,_n... _ C'Q/= Application No.
Judith T. Terry, Town "Clerk
Town Hall, 53095 plain Road 1:-.2.0, k ',. •c $10.00 - Residential
O. Box 1179 Er' % hWk �i �
P. � f:==<t �.��.� � �� $25.00 - Non-Residential
Southold, New York 11971 O ® ��`
Telephone 01 �® ���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /.
Fee $ 7.0„ c3
DATE ! /qD
. OWNER NAME: Mf 2�1„2 /z'. /V , /l�oc_e N G
OWNER MAILING ADDRESS: / N0,c S�S
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OWNER PROPERTY ADDRESS: _?o /7/2/9-7 .e, 2-v-e l
/S/c4P JZE'L /U7
OWNER TELEPHONE NUMBER: -��iy� �0----
TAX MAP NO. : Section l'estrisiBlock Lot 1---79641
6
CROSS STREET: AE ) ae_ c-Q3
TYPE OF SYSTEM: Septic Tank c/ New Existing i ,
_, Cesspool New Existing
Residential i Non-Residential /
DATE OF PREVIOUS PUMP-OUT: 7/c/,,P/
1
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 f App,1f�C` t
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RECEIVED BY: / / G G/
Tjown /C er, s Office
DATE: /, 1 9'�
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DLO NO, TAXI AP DOD 861 L.D-r l`'1- -18 q'
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