HomeMy WebLinkAboutAllison %
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®(l'' '' Town Hall, 53095 Main Road
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c P.O. Box 1179
' _- � ��,�!�� Southold, New York 11971
JUDITH T.TERRY „�,,,,- FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 1575-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ALLISON, DAVID W., JR
Mailing Address 1 142 PINE STREET
Mailing Address 2
City St Zip GARDEN CITY NY 11530-0000
Property Address 1 820 EAST ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-746-0012
Tax Map No. section 110.00 block 7 lot 22.000
Cross Street FLEETWOOD ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/30/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE,-.DF THE TOWN CLERK c0 W '
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• Town of Southold AS
-DJ:-
C'OG� Application No. / D�
Judith T. Terry, Town Clerk w4."5 X4'7 $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 117911. Y~' ° '
cr's k.s �.�""� '��` $25.00 - Non-Residential
Southold, New York 11971
Telephone Y►�� •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ f
DATE / 10--'7 O
OWNER NAME: � ° ' �- ,CLt Ste• ® •
OWNER MAILING ADDRESS: I f dq kLe Cr772-ee-P
OWNER PROPERTY ADDRESS: g )./ _ C'c dr 12-0)4-4
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OWNER TELEPHONE NUMBER: ...37(c, - 7 .�
TAX MAP NO. : Section PO Block 7 Lot
CROSS STREET: FL-eel-Lei
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool )\ New Existing
Residential g_ 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 if Applican
RECEIVED BY:
-1Wr-eiti&-k's Office
DATE: OCT 3019 U
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