HomeMy WebLinkAboutBuckley AAA`' lam.
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% `, 4--'.-P, 1 ',y Town Hall, 53095 Main Road
=�® ;" - - ��: P.O. Box 1179
_� .�! Southold, New York 11971
JUDITH T.TERRY
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-'_�������/0°' TELEPHONE 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. 1255-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BUCKLEY, EDWARD W.
Mailing Address 1 107 BROOK STREET
Mailing Address 2
City St Zip GARDEN CITY NY 11530-0000
Property Address 1 SALT LAKE VILLAGE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-741-2693
Tax Map No. section 144.00 block 5 lot 20.000
Cross Street OLD SALT ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/28/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
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Town of Southold + C'� = Application No. /
Judith T. Terry, Town Clerk • y0„ = '��`
Town Hall, 53095 Main Road '''" C I $10.00 - Residential
P. O. Box 1179 : >;
U-3 c . .>,: . :•i r
0 p �••• $25.00 - Non-Residential
Southold, New York 11971
Telephone viJEI )\00�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /
DATE ,A(/ 5
'y/
OWNER NAME: / dwod L zLk/
OWNER MAILING ADDRESS: / 7..Zgta/l S7
/ /aie,@i74Y A! y, j/c3C
OWNER PROPERTY ADDRESS: SI •]L Leine ),/, //a' `e
OWNER TELEPHONE NUMBER: 4-5-76-
3
32z1s- - - 02-®
TAX MAP NO. : Section / Block CVS -02)6 Lot /) fP3
CROSS STREET: d .-s / At.t. a
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 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.)
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Signa ure of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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