HomeMy WebLinkAboutYoung (5) JUDITH T. TERRYz `4 Town Hall, 53095 Main Road
•TOWN CLERK ® Fri P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � •� Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER
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Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2062-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner YOUNG, T. GORDON AND NOLA
Mailing Address 1 C/O KEMEYS COVE -
Mailing Address 2 P. O. BOX 128
City St Zip SCARBOROUGH NY 10510-0000
Property Address- 1 1555 BAY HAVEN LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 914-941-2042
Tax Map No. section 88.00 block 4 lot 39.000
Cross Street MAIN BAYV I EW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/03/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •COFOUr --
T,own of Southold �� CQG' Application No. 6230 oL
Judith T. Terry, Town Clerk -% �'1
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cr) ' x r - , n % $25.00 - Non-Residential
Southold, New York 11971- O ?=® �
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Telephone -
•
(516) 765-1801 . •
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ '
DATE c — ---2 _�=---
Go/Q.1)ON YOU A16-
/
OWNER NAME: �� ,C
"g'i &-7.5 o Kim Cys coves
OWNER MAILING ADDRESS: �. o . ,i5a 7C J� p O-fox /dA'
-___<.C.-,7,<. �oc,/3A A/ /&5�/G
OWNER PROPERTY ADDRESS: _4�— ,6 --/ .,
OWNER
OWNER TELEPHONE NUMBER: - / / _ ----- 1 -----..2--el 2—
TAX MAP NO. : Section Block Lot -E
' CROSS STREET/ �4 717/ Z 61 , _ 1l -&-'l'i (9
TYPE OF-SYSTEM: Septic Tank New Existing
Cesspool t New Existing /
Residential ,V Non-Residential
ATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approxim -ly, to building and closest road.)
pit/60
1k/1CP'A' ��of, Signat re of Applicant
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RECEIVED -BY-:
Town Clerk's Office -
DATE:
TOWN OF SOUTHOLD ' ;` Ticke ,No: ' 8909
. /kJ"'.II' .
IFNI(
t r ;,.- ,',Com- �•
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o 0''-'':$.02'•-pe'r`'gallon -
SCAVENGER WASTE REPORT _ o! ,�qo ,•,,: per
- -. Fee$• -.. : paid„
. _ Date//%C.5% aid
' Name of Hauler. . . • • - - -
•Southold -Town Clerk
Permit Number 7
Truck.Capacity . . .3.6P•Q • • . . . . Gallons Liquid Waste • : ,
Date Pumped. . : . . . ° �. 2!(r`1,.-: . . . . . . . . -, -- - - ,
Residential Commercial Restaurant"
❑ SPLIT LOAD @ Gallons
Location:
Name of Owner , • _� •�;-- ��•
Street ./..S-.:5-.7. • _ /14.1,1:- .17n:4,7.. .arnlet:..UCerli...K..il
. . •-• _
, „ , Telephone Number x3Ma'pAuriEser' -'` •,.
Cross Street
Diagram (locatin building and cesspool. Give .north-' arrow sand'feet,,_.o "distan , -
approxima ly.)
a
:
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. //, :16—- ,= ,,‘.:-. -,14,/, ,:''',—-- '
I hereby certi y that the above originated within the Town of Southold/Town'of Shelter
Island at the a ove location(s), and to the best of myknowledge,,contains no chemicals, ,
hazardous, o toxic wastes. False statements m'ade]`hereiri _are'.'punisha6le`-as a mis- ,
demeanor pursuant to Section 210-45 of t e Penal--Caw:-of the State ofn,New,York, and
may result in my arrest and the imp d of th ,veh' :'I•am driving.' '',; `• • ` ,
Name of Driver . . . 1s ' . . ' ' ' ' '
Signature of Drivel-4 0 • •' u, : , ;
Received b f
• 4• Time, ,,--'.,).'-.-:.;-'-/:,-.-.-,.'j.;,, ,
Date '� �'
(1)'Treatment Plant . -). -;'!'1.:'''':,,�,�"s;•4, , -