HomeMy WebLinkAboutConnolly c5 Ito
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Town Hall, 53095 Main Road
) P.O. Box 1179
j <1\-0-or Southold, New York 11971
JUDITH T.TERRY
'" 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. 1296-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CONNOLLY, MICHAEL J.
Mailing Address 1 715 LIBERTY LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 715 LIBERTY LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2169
Tax Map No. section 79.00 block 6 lot 6.000
Cross Street COLONIAL
Date Of Last Pump Out 0/00/00
Issue Date: 11/08/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
, • ... ''
OFFICE OF THE TOWN CLERK ��F�
•
Town of Southold �� C'�G• Application No./`Z4.
Judith T. Terry, Town Clerk • t-,,,-t
Town Hall, 53095 Main Road xi, -'c $10.00 - Residential
'fix z y ��
P. O. Box 1179 �: �' 1�y ; $25.00 - Non-Residential
Southold, New York 11971
_ off.'••
Telephone *1.14( `�� •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $ •
DATE // •-- e2
OWNER NAME: h'll d-hae/ ,/. lor) r)o/`
•
y
OWNER MAILING ADDRESS: 7 /c6 L%,6 el^V
60-Lc,A I
OWNER PROPERTY ADDRESS: X519 s'n e
OWNER TELEPHONE NUMBER: 71e5 - a / lag
TAX MAP NO. : Section 79 Block 6 Lot 6
CROSS STREET: 4049,0 /d
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: // -3 -P7
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.)
Signatu,i of Applicant
RECEIVED BY: cpip,�i-
TowreClerk's Office
MEI ED
DATE:
NOV 08 198
Tem Clerk Southo9 l'
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