HomeMy WebLinkAboutBrown (4) CZ3
c 1 „ Town Hall, 53095 Main Road
P.O. Box 1179
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* Southold, New York 11971
FAX 765-1823
JUDITH T.TERRY TELEP O(NE(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. 1516-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BROWN, JEROME
Mailing Address 1 1320 LITTLE PECONIC BAY ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1320 LITTLE PECONIC BAY ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5946
Tax Map No. section 111 .00 block 14 lot 19.000
Cross Street WUNNAWETTA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/10/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFF`I`CE •OF THE TOWN CLERK 'QcwFFtirC'
Town of Southold � � Application No.
Judith T. Terry, Town Clerk 44 •;1.4:
$10.00 - Residential
Town Hall, 53095 Main Road ^� "+ .
P. O. Box 1179 tr3 � �';41)' $25.00 - Non-Residential
Southold, New York 11971 O ' ,..rO� ���
Telephone �� ".
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. `L
Fee $ /o
DATE ql/6 S f 0
'OWNER NAME: ` a-1�1a F .P®c„t9 efo a
•
OWNER MAILING ADDRESS: (32-0 'raw= R
0 'a 11 er all wss, . (c175
OWNER PROPERTY ADDRESS: _zgL
OWNER TELEPHONE NUMBER: (Tie) 7 3 cif S'e/-(
TAX MAP NO. : Section it Block 14 Lot (
CROSS STREET: Gil V mit)Sera 7-7-74 /7 1)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V Non-Residential
DATE 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, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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