HomeMy WebLinkAboutAdams (2) JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK i P.O. BOX 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS =+
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MARRIAGE OFFICER J • y` ',y Fax (516) 765-1823
�•, _,;- ,„�' Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1601-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ADAMS, REGINALD
Mailing Address 1 670 KERWIN BOULEVARD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 670 KERWIN BOULEVARD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0176
Tax Map No. section 53.00 block 6 lot 42.000
Cross Street ISLAND VIEW LANE
Date Of Last Pump Out 0/00/86
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
,Town of Southold ,�UFF� PO (0�� �eoG' Application No.
Judith T. Terry, Town Clerk % :rf`<..,L-... x. . `'1 $10.00 - Residential
Town Hall, 53095 Main Road a -.215:4.
P. O. Box 1179
to ``Y >�,, �'�' ` � ` $25.00 - Non-Residential
Southold, New York 11971 p � 4`" .$
Telephone .10 � ��O .°4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /01—
.
Q,—
DATE/, / 0/
OWNER NAME: Y Q i - Q
OWNER MAILING AD RESS: 6 6 ��
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OWNER PROPERTY ADDRESS:67Ug4
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OWNER TELEPHONE NUMBER: .77----0,/u
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TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing X
Cesspool XI-C,'2t454=7,AipNew Existing j(
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: ? �,�,._,,,1-- q-,fr., . iv�- �•1 , .w
LOCATION MAP: Must be attached hereto before permit may e issu-/
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
0111! 4. /At( ` /4/ eillAdA4f
/gnature o Applicant
RECEIVED BY: o(°
TdfiiritG:le"ti'k's Office
DATE: DEC I._ "1 .;:,1,)
Town Clerk Southold
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