HomeMy WebLinkAboutBrooks (3) 0c),#fo o'
Town Hall, 53095 Main Road
Vii`` P.O. Box 1179
�°a .��� Southold, New York 11971
43 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. 1206-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BROOKS, SHELDON H
Mailing Address 1 BROOKS, MARGARET G.
Mailing Address 2 P. O. BOX 275
City St Zip GREENPORT NY 11944-0000
Property Address 1 465 MIDDLETON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 415-477-0704
Tax Map No. section 40.00 block 5 lot 13.000
Cross Street NORTH ROD
Date Of Last Pump Out 0/00/00
Issue Date: 8/04/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cOF air
Town of Southold Application No.
Judith T. Terry, Town Clerk ` 1. „: �`
Town Hall, 53095 Main Road " :', $10.00 - Residential
P. O. Box 1179 U s '`t ` ,
• Southold, New York 11971 O x4 ," �••� $25.00 - Non-Residential
Telephone Q( , `j0••
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ri?
•
DATE 9
cS
OWNER NAME: 5 5-1411. W . •
OWNER MAILING ADDRESS: 4.(Oj ,L
4
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 0—,/ lit- 7 rf 0 ® LA
TAX MAP NO. : Section Block ,.�'�' Lot / 3
CROSS STREET: 797 �
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool /1 New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6_/[ / St 7
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.)
A('G 041989J'Gel6 7�1�-
Signature of Applicant
Town . g p p
RECEIVED BY:
Town Clerk's Office
DATE: ff-/3/ 6f
Sheldon H. Br-ooks &
465 Middleton Rd. , Greenport, N.Y. 11944
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_House --
Middleton Road
Tax Map No. : Section 40
Bl. 5
Lot 13
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