HomeMy WebLinkAboutCoulter cOf
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® al Town Hall, 53095 Main Road
° ��` P.O. Box 1179
,ss22, ��n�±" Southold, New York 11971
JUDITH T.TERRY " _ `2s FAX� FAX(516)765-1823
IOL1 TELEPHONE(516)765-1801
TOWN CLERK
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. 1339-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COULTER, FREDERICK
Mailing Address 1 122 BROMPTON ROAD
Mailing Address 2
City St Zip GARDEN CITY NY 11530-0000
Property Address 1 7020 PECONIC BAY BLVD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-294-8025
Tax Map No. section 126.00 block 11 lot 6.000
Cross Street BRAY AVENUE
Date Of Last Pump Out 0/00/78
Issue Date: 12/11/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
, •-
.
if OFFICE OF THE TOWN CLERK f-FO(�,�'-
Town of Southold ' -‘ 1' :141..`;r•-
`� 4r, t('�G-, Application No. /339
Judith T. Terry, Town Clerk % 44 '' '''41 k :•�
Town Hall, 53095 Main Road ,� . . $10.00 - Residential �r/
to `{�� x'... �,�`
p. O. Box 1179 .Y.- h�i % $25.00 - Non-Residential
Southold, New York 11971 O `' > -r 0�,��
Telephone 'Q( y `W;
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 1 ( 41177- ,
OWNER NAME: /` t[,.e�7&iy J 1 ,Dti /y&g •
•
•
OWNER MAILING ADDRESS: / ).---",- 6,1)/A 0 -
.,.1.4 1.) l'741 _ ,' ,/,_ • ' 3d
OWNER PROPERTY ADDRESS: 1 1 '
OWNER TELEPHONE NUMBER: v ,-' To 24
TAX MAP NO. : Section `,2G , 0 0 Block 0/7, 0 o Lot 00 C e 0 0
CROSS STREET: SCcl- 8,----2-0-ivitilli; J & c ,
TYPE OF SYSTEM: Septic Tank ` /
New Existing /
Cesspool /.77-
' New Existing 1..-/-/-
Residential ' (...-"v"-
Non-Residential
DATE OF PREVIOUS PUMP-OUT: .-Cbfi4444-4.11, / 9 7 S.
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.)
---- 0 it/ 1.4 ,e/ / /-, -. ,
Signature > jc
t
•
RECEIVED BY: d- -y ,_Q ,7o ,
Town Clerk's Office
DATE: RECEIVED
DEC i l 1989
Town Clerk Southold:
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