HomeMy WebLinkAboutCoffey JUDITH T. TERRY L Town Hall, 53095 Main Road
TOWN CLERK : P.O. Box 1179
REGISTRAR OF VITAL STATISTICS `' Southold, New York 11971
MARRIAGE OFFICER V/ �� Fax (516) 765-1823
®4ti°® a40 1 Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1725-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COFFEY, TIMOTHY
Mailing Address 1 44900 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 44900 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2554
Tax Map No. section 75.00 block 6 lot 7.001
Cross Street ROBERTS LANE (ROW)
Date Of Last Pump Out 0/00/87
Issue Date: 7/24/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c.0FOW'
- Town of Southold r - Application No. - '`^
Judith T. Terry, Town Clerk % ,`4i y
Town Hall, 53095 Main Road
g -..,'..-x:,;.2-;, .G ) $10.00 - Residential
P. O. Box 1179 a �" '
,. 3-, � ,�. $25.00 - Non-Residential
Southold, New York 11971 0 '42i t $Telephone �?i 0-1
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT CIL.Q_CL 6 ,/
APPLICATION ‘kk
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for Cc®i
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1-�7
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Fee $ / 0
. ' DATE eV/ V9/
OWNER NAME: ';Ayori/ eoi pl Ln,4 9 , w/ &Air/ekei®rs/14eSE7
OWNER MAILING ADDRESS: NA/AJ ktt, p,41ffii,i -
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OWNLK 1-"k0FER T it ADDRESS: -- 504-14L
OWNER TELEPHONE NUMBER: 71.5"- .?,./-.0-!
TAX MAP NO. : Section 75 Block i 6 Lot 7 /
CROSS STREET ce-ARO b rLr`t-S La._ILA_ (16DO 4-- E . Oic 4.cai,, (c_ La )
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 11"../ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: (ZIi�I 3 y4.-4),,
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LOCATION MAP: Must be attached hereto before ;permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to buildi f"• and dos; road.)
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7 Signa re Applicant
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RECEIVED BY: #1. il-A-A....-/A-c_
Town Clerk's Office "
DATE: -7 — i "2 — 9(
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