HomeMy WebLinkAboutAdams (2) ,'1®c) II l�l� tt
,; Town Hall, 53095 Main Road
O �� P.O. Box 1179
fzn ®i�� 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. 1177-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ADAMS, WILLIAM E., JR.
Mailing Address 1 19 MIDDLETON ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 19 MIDDLETON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0301
Tax Map No. section 40.00 block 5 lot 7.000
Cross Street WILMARTH AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/27/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF T.HE.;"f W- el CLERK ��FD
Town of Southold � �� Application No. #11
Judith T. Terry, Town Clerk .`, ,yf . '�
Town Hall, 53095 Main Road g $10.00 - Residential
P. O. Box 1179 cn $25.00 - Non-Residential
Southold, New York 11971 O Telephone
'`•
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- - , - - for
-OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /oZ•Ve?
OWNER NAME: ) //e7r»
OWNER .MAILING ADDRESS: /9 /�'JI a/ /e_-7 ,7 'eV•
__^OWNER.PROPERTY _ADDRE,SS=: • - -- --
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing •
Residential Non-Residential ` ;,'i.
DATE OF PREVIOUS PUMP-OUT: /lict/efr t
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.)
` _ k
Sig ature o• Applica t,
RECEIVED BY:
Town Clerk's Office
DATE:
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