HomeMy WebLinkAboutClark 44 s
YW.�y ,I1 Town Hall, 53095 Main Road
` P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ',OS° 3
TELEPHONE) 16)765 182 765-1801
TOWN CLERK
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. 964-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CLARK, LLOYD H.
Mailing Address 1 10005 SOUNDVIEW AVENUE
Mailing Address 2 RFD 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 10005 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2253
Tax Map No. section 59.00 block 2 lot 6.000
Cross Street KENNY ROAD
Date Of Last Pump Out 0/00/84
Issue Date: 12/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK C�V�F�(�'�'-
Town of Southold C 2
Judith T. Terry, r �� Application No. (o
Town Clerk `
Town Hall, 53095 Main Road h -� } Residential
P. O. Box 1179 � k. Non-Residential
Southold, New York 11971 • OR
Telephone - - �,( -ift
(516)- 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE ,._.;;2e,<° � %988
OWNER NAME: 7 / .ee"
/p ���•_ -
OWNER MAILING ADDRESS: ,e/-")
Yy
OWNER PROPERTY ADDRESS:OWNER TELEPHONE TELEPHONE NUMBER: ,j--/C-7‘:6-- ,e,_ 33
TAX MAP NO. : Section �� Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ' New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /2fl
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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