HomeMy WebLinkAboutCollins Z/Zf`fi /�.'
Town Hall, 53095 Main Road
r„ ' ' =" '" � i�' P.O. Box 1179
'',-*62 . s Southold, New York 11971
JUDITH T.TERRY0.° Fax(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 961-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COLLINS, LEROY
Mailing Address 1 MAIN ROAD
Mailing Address 2 BOX 771
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-3279
Tax Map No. section 122.00 block 6 lot 18.000
Cross Street FACTORY AVENUE
Date Of Last Pump Out 0/00/85
Issue Date: 12/15/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �c3IFO(,r�'=
Town of Southold C'
�, Q ' Application No. 96 f
Judith T. Terry, Town Clerk .� „�?
Town Hall, 53095 Main Road `'=": . I Residential 6.-"'"--
P.
/P. O. Box 1179 to tit Vis;r. i ; Non-Residential
Southold, New York 11971 O�i� �- �1`,
Telephone _ j ' ''
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
\
Operation Permit No. Q l
Fee $ /()
DATE 1/1 .2 F(f.-'
-,/ -
OWNER NAME: .--"" r.z., (.2_
OWNER MAILING ADDRESS: '(291,-- 7 7 1- /./i4�
OWNER PROPERTY ADDRESS: ?q 9 '2fv7" "_-/17
OWNER TELEPHONE NUMBER: , 99 k'- 3 62- 7 i
TAX MAP NO. : Section /2 2- C49-`?' Block Lot
CROSS STREET: / GI..C. -, ( Q_
TYPE OF SYSTEM: Septic Tank I / New Existing
Cesspool (/ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 9 l3- :-
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.)
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• . . ,
c—r
Sig ature of Applicant
RECEIVED BY: '
Town Clerk's Office
DATE:
-41 4 -- _ ®
071/L
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