HomeMy WebLinkAboutBurns (3) LL
Town Hall,T. TERRY 53095 Main Road
TOWN CLERK P.O.P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
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Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1859-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BURNS, CATHERINE D.
Mailing Address 1 2433 CAMP MINEOLA ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2433 CAMP MINEOLA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5786
Tax Map No. section 123.00 block 6 lot 7.001
Cross Street ALOIS LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/25/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
O)AFICE OF THE TOWN CLERK •�VFFD(K�' GG
Town of Southold , �� .. : CQG Application No. /D
Judith T. Terry, Town Clerk �� ' ' y
$10.00 - Residential
Town Hall, 53095 Main Road
P. 0. Box 1179 cr3 �_ ;'
� �,.•. �+s• • � � $25.00 - Non-Residential
Southold, New York 11971 O O� -�`
Telephone *0 �� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10d0-0
DATE ( ARCt f `Nc;),
OWNER NAME: QA4-•SIL l C . .:60M3
OWNER MAILING ADDRESS: cAl'{'LM CAMP (1'1tor:-°LA ROA
) fJ elk.) YoR.K 119
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OWNER PROPERTY ADDRESS: a.L-33 CA pip m I il7EO'A -KO A N
frIPrierrOCK ) 1Q E LL) `/O IAF- [ i95
OWNER TELEPHONE NUMBER: 51(0 51Vp
TAX MAP NO. : Section l Block Co- 7 Lot I
CROSS STREET: ALO1S 1,..1 nJ
TYPE OF SYSTEM: --Septic- Tank New Existing
Cesspool ,/ New Existing
Residential Non'Residential
DATE OF PREVIOUS PUMP-OUT: 1" CQ ROA-g_Y'
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.)
$46.(AA,,L,LJ
Signature of Applicant
RECEIVED, BY:
TownClerk's Office
RECEIVED
DATE:
MAR 2 10c
Town Clerk grant old
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