HomeMy WebLinkAboutBaldwin k-
��`" Town Hall, 53095 Main Road
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® et P.O. Box 1179
----242.1 sii IP:,.0 Southold, New York 11971
JUDITH T.TERRY ,, ,,,,f0- 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. 1512-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BALDWIN-LAUB, SANDRA
Mailing Address 1 P. O. BOX 1945
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 545 HUMMEL AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4779
Tax Map No. section 63.00 block 2 lot 18.000
Cross Street YOUNGS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/06/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
91 ' III
OFFOF THE TOWN CLERK c��FFO(,r
Town of Southold �0 ; ��G Application No. /5762-1
Judith T. Terry, Town Clerk 1.14
Town Hall, 53095 Main Road $10.00 - Residential �� , 0
P. O. Box 1179 cn { *Yi
$25.00 - Non-Residential
Southold, New York 11971 �`,'� f
Telephone `t 0�°�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT •
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • 10 .00
DATE or/ 1 ,373 Ig°
OWNER NAME: Sfl � Ii'tf - Lau-
•
OWNER MAILING ADDRESS: BOX fq Cis'
OWNER PROPERTY ADDRESS: 6t-IS I(4mir.e ,five
t ikidholci l5N. 1Lc? -11
OWNER TELEPHONE NUMBER: GU° - 7(0S-- ' I77 ?
TAX MAP NO. : Section 0(0'3 Blockt:::2Lot )
CROSS STREET: )1OL4fl5 AoQio ,
TYPE OF SYSTEM: Septic Tank New Existing 74.
Cesspool New Existing
Residential 4-- Non-Residential
DATE OF PREVIOUS PUMP-OUT: 0-14J')1, ,Q I ° ('n
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.)
I
Signature o App icant
RECEIVED BY:
Yo 'ia-Clerk's Office
DATE: AUG 06 1990
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I FW-70A/1004A PDM86 C 1984 Forms and Worms®Inc.,315 Whitney Ave,New Haven,CT 06511 All Rights Reserved 1(800)243-4545 585 Item# 112150
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