HomeMy WebLinkAboutClemens Town Hall, 53095 Main Road
P.O. Box 1179
„•°.
Southold,Southold, New York 11971
JUDITH T.TERRY r'•'••� 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. 951-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CLEMENS, JOHN AND MARY
Mailing Address 1 7630 MAIN BAYVIEW ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 7630 MAIN BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2529
Tax Map No. section 87.00 block 5 lot 16.000
Cross Street CEDAR DRIVE
Date Of Last Pump Out 0/00/85
Issue Date: 12/12/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK r--X c0FD(,(r"
Town of Southold C'
0, ", OG Application No."-c'
Judith T. Terry, Town Clerk . r. : y
Town Hall, 53095 Main Road -' 7 Residential
P. O. Box 1179
Southold, New York 11971 Non-Residential
p
Telephone - - OjjigY►�
1516) .765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT"
SEPTIC TANK or CESSPOOL
Operation Permit No. Q31
Fee $ l
DATE' lis "/ F
OWNER NAME: 0f1 xt NA y s
OWNER MAILING ADDRESS: 7636 %
At,j11,-1-e-
‘Sei 041) NY /1771
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: ��"' 3 j
419
TAX MAP NO. : Section � Block Lj Lot /6
CROSS STREET: Z'€ MR. DQ/0e--
TYPE
f /Ue--TYPE OF SYSTEM: Septic Tank New Existing x
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: A V(qD S(l
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.)
ignature of Applicant
RECEIVED BY: t (p� Q
own Clerk's Office
DATE: (; o2/ice
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