HomeMy WebLinkAboutBrown (4) OFFICE OF THE TOWN CLERK • CO Wei;
Town of Southold -
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179 to
Southold, New York 11971
Telephone WO1��
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
, Operation Permit No. 361 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool ; X
NAME OF OWNER: Kenneth G. Brown
OWNER MAILING ADDRESS: P.O. Box 1431
Mattituck, N.Y. 11952
OWNER PROPERTY ADDRESS: Westphalia Road #3530
Mattituck, N.Y. 11952
OWNER TELEPHONE NUMBER: 298-8313
TAX MAP NO. : Section 114 Block 1 Lot 9
CROSS STREET: Route 48
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 1985
T• 1
Judith ,T1 -Ter
Southold Town Clerk
DATE: July 23, 1987
(TOWN SEAL)
- •
s,
OFFICE OF THE TOWN CLERK F (�Town of Southold (Pei
,w� . CQG Application No. � 61, ,
Judith T. Terry, Town ClerkTown Hall, 53095 Main Road ": :G 1Residential
P. O. Box 1179 `' ;' Non-Residential
Southold, New York 11971 ® Q ���`Tele hone ', "
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. s'g
Fee $ /Q.)
DATE Cj /c > /PJ?
OWNER NAME: / nre14 ,a/goal//
OWNER MAILING ADDRESS: p
Box /V3l
OWNER PROPERTY ADDRESS: 2 <IA4 ,'g R 04 &."-go
Ab azLi_ lv y //f3-2--
OWNER
lls`zOWNER TELEPHONE NUMBER: avg ` s°,34y
TAX MAP NO. : Section 1/ Block U Lot trt
CROSS STREET: a'
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool f , New Existing
Residential Y Non-Residential
DATE OF PREVIOUS PUMP-OUT: - � /?(Lr
LOCATION MAP: Must be attached hereto •efo(e permit may be issued.
G;���,,, (Locate building and system; give north arrow and feet
""""�1- `- - - of distance, approximately, to building and closest road.)
Writ
4‘,0_1+4/Do'
4"1"--, .44/65t
{ 33-Sp Signature of Applicant
RECEIVED BY: rf� i��_
• if
•wn Cl-rk's 0 fice
DATE: /F7