HomeMy WebLinkAboutBuckley (2) OFFICE OF THE TOWN CLERK :c5IFOCJ(e"
Town of Southold �
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Judith T. Terry, Town Clerk TMs, '4
Town Hall, 53095 Main Road c , -ra4
P. 0. Box 1179 v' XY
A ,t4-44,7
Southold, New York 11971 `Y ®
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Telephonestt�,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 472 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Eugene T. Buckley
OWNER MAILING ADDRESS: 14 Keenan Place
Garden City, New York 11530
OWNER PROPERTY ADDRESS: 5 Sandy Beach Road
Greenport, New York 11944
OWNER TELEPHONE NUMBER: 516-248-6121
TAX MAP NO. : Section 3 Block 3 Lot 29
• CROSS STREET: Beach Street
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
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Southold Town Clerk
DATE: October 27, 1987 •
(TOWN SEAL)
4.`r
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OFFICE OF THE TOWN CLERK %IFNI(
Town of Southold .�.. a CSG'- Application No. e-/1°
Judith T. Terry, Town Clerk ♦ r'.:
Town Hall, 53095 Main Road a r -4 Residential
p. O. Box 1179 t' =st: �` Non-Residential
41 yw
Southold, New York 11971 O • �• O ♦�`
Telephone -_41.1y
(516) 765-1801 •
RECRVED TOWN OF SOUTHOLD
OCT19 P:7 SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Ton Cketl soutioi
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. '4/7'''
Fee $ / b"
DATE 1Q) ( l -) (2
OWNER NAME: li- fir) OA. L \Q-,
OWNER MAILING ADDRESS: t et)A--It/
&ca ckf Y ( 1 c .10
OWNER PROPERTY ADDRESS: S
OWNER TELEPHONE NUMBER: ( � � l(0 24
•
TAX MAP NO. : Section Block d Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing c/
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
S of distance, approximately, to building and closest road.)
Signature of Appl cant
M
Town Clerk's Office
DATE: RECEIVED)
OCT 2619 7 ..
Town Clerk Southold