HomeMy WebLinkAboutCharles JUDITH T. TERRY ,
Town Hall, 53095 Main Road
TOWN CLERK ® %y P.O. Box 1179
REGISTRAR OF VITAL STATISTICS :�� Southold, New York 11971
MARRIAGE OFFICER G V. Fax (516) 765-1823
'e ' 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. 1894-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CHARLES, ANN C.
Mailing Address 1 P. O. BOX 1546
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 37835 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5144
Tax Map No. section 115.00 block 16 lot 21 .000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/84
Issue Date: 5/11/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c3VFFOUrp--
Town of Southold �� C2 '_ Application No. / �f' /
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Judith T. Terry, Town Clerk �
Town Hall, 53095 Main Road x - 7 $10.00 - Residential
P. O. Box 1179 cn 1,4.7; �r;' moi,; $25.00 - Non-Residential
,Southold, New York 11971 ff`!
Telephone '�l
(516) 765-1801 �
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee'$ I
DATE l
OWNER NAME: eZ24,42L-icti
OWNER MAILING ADDRESS: / •eer- . r j 66
OWNER PROPERTY ADDRESS: _-a - CA/
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OWNER TELEPHONE NUMBER: g ' _
TAX MAP NO. : Section lI 5 Block i (p Lot 7Z
CROSS STREET: NeW
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool K- New Existing X
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.)
,62)ere)--S
Signature of Applicant
RECEIVED BY: AL-) /1(��
Town Clerk's Office
DATE: 5 - f �
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