HomeMy WebLinkAboutCampbell JUDITH T. TERRY • ` Town Hall, 53095 Main Road
TOWN CLERK P.O.►rT Box 1179
REGISTRAR OF VITAL STATISTICS tin
� Southold, New York 11971
MARRIAGE OFFICER V. Fax Fax (516) 765-1823
Wei slit�-__4 j 1a® '� Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2011-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CAMPBELL, CHARLES H.
Mailing Address 1 P. O. BOX 169 -
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 15155 MAIN ROAD
Property Address 2 (PRIVATE ROAD #8)
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-0650
Tax Map No. section 23.00 block 1 lot 15.000
Cross Street EAST OF DAM POND
Date Of Last Pump Out 0/00/00
Issue Date: 12/02/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COMA'
Town of SoutholdCSG•. Application No.a O /7'
Judith T. Terry, Town Clerk 4fi. y
Town Hall, 53095 Main Road «rte $10.00 - Residential 47--`
P. 0. Box 1179 " wi• ��` $25.00 - Non-Residential
KT'Southold, New York 11971 � ".�0 �`
Telephone .(
(516) 765-1801
TOWN OF SOUTHOLD
,SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE MD//,
OWNER NAME: (?,% r2 /1 2ampAe//
OWNER MAILING ADDRESS: Po 254 /4 ,
OWNER PROPERTY ADDRESS: /5/53 n cYjvC, '-
OWNER TELEPHONE NUMBER: (.5/a-- 4Z '7f--(55b
TAX MAP NO. : Section 23. Block / Lot
CROSS STREET:
TYPE OF SYSTEM: Septic.Tarik- -New Existing
Cesspool New Existing " I
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4j' P(„),30 ej OUi 1�1 e,
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.)
i. d L
ignature of Appl' ant
RECEIVED. BY: , - -
Town lerk's Office
DATE: NOV
IMv
Town Clerk Southold
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