HomeMy WebLinkAboutAsip 410 P
06 CN4
Town Hall, 53095 Main Road
P.O. Box 1179
,� ��� Southold, New York 11971
JUDITH T.TERRY
TELEPHONE(51)76516)7823
65 1801
01
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. 986-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ASIP, WILLIAM M.
Mailing Address 1 8255 BRIDGE LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 8255 BRIDGE LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5644
Tax Map No. section 84.00 block 1 lot 4.000
Cross Street OREGON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/10/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFill`I�'
<rz -Town of Southold NQS , CQ ' , Application No.
Judith T: Terry, Town Clerk
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Town Hall, 53095 Main Road a
n�i` .1�;{ yResidential
P. O. Box 1179 cn � t-Y' i ; Non-Residential
Southold, New York 11971t‘ -
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Telephone _Q( *
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE f/V '
OWNER NAME: V/�L/ f'/ / 1--,17(
OWNER MAILING ADDRESS: P-2---6"Y !3 !j7) / ,9i'
Gv i ) v , /77
1.--77/,;-_
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:( ,)73 - reyef
TAX MAP NO. : Section J "/ Block / Lot
CROSS STREET: /
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool <' New Existing A-
Residential 2( Non-Residen ial
DATE OF PREVIOUS PUMP-OUT: ( j _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.)
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Signatur- of Applica t
RECEIVED BY• �„ 9� ,
� �°;06T�own Clerk's Office
DATE: 1111 O q
Town Clerk Southold
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