HomeMy WebLinkAboutButkus •
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grt Town Hall, 53095 Main Road
P.O. Box 1179
$— oir Southold, New York 11971
JUDITH T.TERRY 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. 1251-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BUTKUS, HILDA A.
Mailing Address 1 6300 SOUTH POINTE BLVD.
Mailing Address 2 APT. 129
City St Zip FORT MEYERS FL 33907-0000
Property Address 1 3575 MILL ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-5678
Tax Map No. section 67.00 block 2 lot 12.000
Cross Street SECOND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ��O
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Town of Southold C' = Application No.
Judith T. Terry, Town Clerk �G
� �G 7 $10.00 -
Residential
Town Hall, 53095 Main Road :r : -
P. 0. Box 1179 ai � $25.00 - Non-Residential
Southold, New York 11971 O °® ti ��•
Telephone '(1( )24 %P
(516) 765-1801
TOWN OF SOUTHOLD 11
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ (O.O-J &La, /4
DATE „" A /
OWNER NAME: 7L-e-4 a ._ .
OWNER MAILING ADDRESS: .�— /, !� •� �j�� c u /uj
fit/ OWNER PROPERTY ADDRESS:Jf'�J"*1.2 / 02
OWNER TELEPHONE NUMBER: 574 -Y76(S 6-6 ze
TAX MAP NO. : Section 6 7 Block Lot ✓
CROSS STREET: �hi.
� -
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential SAV Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4,-/e.,va.
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.)
idfr Pet-eLe_
07.114617,4,c4 a
g,�7� Signature of Applicant
RECEIVED BY:
Town Clerk's Office /
DATE: MD
SEP 2 51969
„,,;� cie!k $o0 4
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