HomeMy WebLinkAboutChilton 4,i4.4tVULte77-;*,
o ;N , Town Hall, 53095 Main Road
P.O. Box 1179
® ,ss22, �����'` Southold, New York 11971
JUDITH T.TERRY ®� �s' ! FAX(516)765-1823
TELEPHONE(S 16)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE -;;;;;;101W-*:CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1347-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CHILTON, ROBERT H. & BLANCHE L
Mailing Address 1 BEACHWOOD LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1. BEACHWOOD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2226
Tax Map No. section 70.00 block 10 lot 57.000
Cross Street CRITTENS LANE
Date Of Last Pump Out 0/00/00
„...„0,040:06,:r110
Issue Date: 12/19/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICEOF THE TOWN CLERK az
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rate
Town of Southold .. � � Applicati6n No. /3C/7
Judith T. Terry, Town Clerk � • � �� ;A ,� v. $10.00 - Residential
Town Hall, 53095 Main Roads u
P. O. Box 1179 cn R ..r taa ; $25.00 - Non-Residential
Southold, New York 11971 F> fa' •-• .1C
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Telephone •-.. .1411% • •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /C•.ee
DATE /. --//cf-/(127
OWNER NAME: A4e.Q / j'd' • N- 734A) C'-1t '`e eA-I#O0iv
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OWNER MAILING ADDRESS: , e4`e% C&Oc, C/ 4 `
got( 7-h.a ice i / ! l v
OWNER PROPERTY ADDRESS: ?V,yj '
OWNER TELEPHONE NUMBER: ---(/6 °f 't5 Z� �
7o /2-4 S 7
TAX MAP NO. : Section Block — � Lot r
CROSS STREET: Ca , 777e Ake k 4
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ��l
Residential �--� Non-Residential
DATE OF PREVIOUS PUMP-OUT: /�/to 8 7
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.)
/e)Cdai -1L-e/1-i-J
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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