HomeMy WebLinkAboutAddy Q F ��
;: 6 r Town Hall, 53095 Main Road
P.O. Box 1179
�® �`ry��,i" Southold, New York 11971
JUDITH T.TERRY �'= ; '����
TELEPHONE(i6)?ssi801
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. 1428-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ADDY, NORMAN
Mailing Address 1 BOX 262
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1120 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8868
Tax Map No. section 114.00 block 12 lot 17.001
Cross Street OLE JULE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FOtir�'-
Town of Southold Q' > C0 •• Application No. /4'2-
r
Judith T. Terry, Town Clerk . xi � y :i
Town Hall, 53095 Main Road `�,ts -< $10.00 - Residential
P. O. Box 1179 to r.Veit
Southold, New York 11971 ®4' �:. , '�,��• $25.00 - Non-Residential
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
• OPERATION PERMIT
• SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE t?//f��
'OWNER NAME: � O 6e in rad cty
•
OWNER MAILING ADDRESS: [v-x ( �.
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OWNER
/ s`•—OWNER PROPERTY ADDRESS_:_ 1 b� (tap- /SAW• ylj�_
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block / Lot 17- /
CROSS STREET: k_eijl ��'rc (= (=y ! �� l/-I✓� -- 3/2 _Ire/� /- ��
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1 New Existing >C
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 0
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximattiy, to building and closest road.)
Signature of • . . icant
RECEIVED BY: ; ,E , 0- ; ;i
no Jerk's Office
DATE: OM 231990
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