HomeMy WebLinkAboutColeman JUDITH T. TERRY ' Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS l .0 Southold, New York 11971
MARRIAGE OFFICER � Fax (516) 765-1823
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� �!_ 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. 1844-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COLEMAN, PETER M.
Mailing Address 1 P. O. BOX 364
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2105 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8154
Tax Map No. section 115.00 block 14 lot 15.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/81
Issue Date: 2/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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( "-FICE OF THE TOWN CLERK c�UFF�(��'=
Town of Southold �� CQ Application No. /NCI
Judith T. Terry, Town Clerk • - �►
Town Hall, 53095 Main Road �" $10.00 - Residential
P. O. Box 1179 u' Wr \tr ` $25.00 - Non-Residential
Southold, New York 11971 0 ` . •�`�,
Telephone '0j �� "
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0.00
DATE L1/7) •
OWNER NAME: /11 CL0 /vJ
OWNER MAILING ADDRESS: ) au 3i
() fl rt)c.16. /J• L/, / 15 8-2,
OWNER PROPERTY ADDRESS: 4 'Dear1 )i-E" a-
r'1 'v1 t,-T-lic,l(.r !0
OWNER TELEPHONE NUMBER: 29g - (F,`g f
TAX MAP NO. : Section //s Block /Li Lot /8-
CROSS STREET: /d/L ' SU6 i� fir✓.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
Residential 7( Non-Residential •
DATE OF PREVIOUS PUMP-OUT: 10 Mies --
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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