HomeMy WebLinkAboutCrenshaw ez:r '
Town Hall, 53095 Main Road
=� � *W ` P.O. Box 1179
�j� ��' Southold, New York 11971
OFFICE OF THE TOWN CLERK
Town of Southold %.” t C'� - Application No. 7�
Judith T. Terry, Town Clerk r �'
Vi4Town Hall, 53095 Main Road Residential .�
P. 0. Box 1179 ul 'Egli i�;' Non-Residential
Southold, New York 11971 p � ���
Telephone
(516) 765-1801
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
----- _for - - - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 7 cilgp
OWNER NAME: \DSrr
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OWNER MAILING ADDRESS: IO `7 `v .�-
OWNER PROPERTY ADDRESS: 10 1
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OWNER TELEPHONE NUMBER: 77 ✓ V/
TAX MAP NO. : Section Block Lot
CROSS STREET: 1nr A- e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential A. Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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
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RECEIVED BYE • _.-.fJ t•/ �� ,; zi/ /
own C I'rk's Once
DATE: JUL 191999
Town Clerk Southold
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