HomeMy WebLinkAboutBittner c=3, '
Town Hall, 53095 Main Road
®� `' P.O. Box 1179
® � Southold, New York 11971
JUDITH T.TERRY FAX 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. 1268-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BITTNER, THEODORE 0., JR.
Mailing Address 1 BITTNER, MADELINE
Mailing Address 2 SOUNDVIEW AVENUE
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2409
Tax Map No. section 58.00 block 1 lot 1 .000
Cross Street KENNEY ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK se
Town of Southold Qc��FF', Q '�
- Application No./02)6
Judith T. Terry, Town Clerk ' A .:a r
Town Hall, 53095 Main Road a ., -• �, , < $10.00 - Residential /O•
P. O. Box 1179 cn s ':; ` 1 j .
�y � � ,{,;,,, � $25.00 - Non-Residential
Southold, New York 11971 p ® .1,6, ` �1�'
Telephone %',014,i--lt. 's0"...
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / - --
•
DATE /0/0?
OWNER NAME: 7/-(e 17'�.C= d. 9/7774 U,cf� J n- (4ñ )
OWNER MAILING ADDRESS: S'O,)A'D' tilEW Alit
S00 777/0 4._P V ((f 7/ -
OWNER PROPERTY ADDRESS: i( c(
41'
OWNER TELEPHONE NUMBER: 76o r 17k�—' p24O 7 r/ I l
a -TAX MAP NO. : Section ��S Block / Lot [
.',fns
Ty
,r i CROSS STREET:.
,,.--`
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool �w Existing
Residential Non-Residential �+
DATE OF PREVIOUS PUMP-OUT: '/J _ (77kie 2!%�' ac.)go
r)
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.)
. 714aJ-dj'ez- °' '-'1 ;ii
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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