HomeMy WebLinkAboutCox ^IPCIV Wire
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Town Hall, 53095 Main Road
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IO ' � �i, P.O. Box 1179
®� j�0 ! Southold, New York 11971
JUDITH T.TERRY ;0
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. 1138-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COX, HAROLD N., JR.
Mailing Address 1 P. O. BOX 597
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 54870 EAST MAIN STREET
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3244
Tax Map No. section 63.00 block 4 lot 2.000
Cross Street TOWN HARBOR LANE
Date Of Last Pump Out 3/00/88
Issue Date: 6/09/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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•
OFFICE OF THE TOWN CLERK C3IFD(e
Town of Southold �� CQ ' Application No. //3r.
Judith T. Terry, Town Clerk .� � '' 0: •
"� ` 5 ;� .G 7 Residential
Town Hall, 53095 Main Road �`
, s 4.>
P. O. Box 1179 Cf7 .� �i � Non-Residential
Southold, New York 11971 *04 �s ��'• 1
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: /444R-0 LP Mr Ce=x 1/L
OWNER MAILING ADDRESS: 0". O. 136 ), 597 �6uT14 cD
OWNER PROPERTY ADDRESS: 5 /c' 70 ��',-S T" MA-in/ PP,
Soya-4 0 1 b
OWNER TELEPHONE NUMBER: 7 & 5 3'-
TAX MAP NO. : Section g 3 Block 4 Lot --
CROSS STREET: /30 r# Ea-ST/recva ff F v�� �'3 �✓r�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ✓d7/-ZCt-1 /`?
Pe?
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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 building and closest road.)
" 74C 1 .
Signature of Applicant/
RECEIVED BY:
To n Clerk's Office
DATE: �j
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