HomeMy WebLinkAboutBranche OFFICE OF THE TOWN CLERK 0FO
Town of Southold ���� `-ef
Judith T. Terry, Town Clerk °t
Town Hall, 53095 Main Road
P. 0. Box 1179 cn
-
Southold, New York 11971 ; :2 f f •
�•
Telephone 0: laci
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 171 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: JOhn B. Branche
OWNER MAILING ADDRESS: 15 Flower Street
Hempstead, New York 11550
OWNER PROPERTY ADDRESS: Siliermere Road
Greenport, New York 11944
OWNER TELEPHONE NUMBER: 481-9682 or 477-1372
TAX MAP NO. : Section 42 Block 2 Lot
CROSS STREET: Shore Drive _ --
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1983
•
• Judith T. Terrf
Southold Town Clerk
DATE: December 8, 1986
(TOWN SEAL)
p
OFFICE OF THE TOWN CLERK
Town of Southold �o Q Application No. /7/
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road t ."r .G Residential
17
P. O. Box 1179 triP
`' Non-Residential
Southold, New York 11971 �Nr ••
Telephone ( to
i 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / /
Fee $ D��
DATE 4A/ / , l l r `'
OWNER NAME: -A/ZNC/1-6 1/ i 7-3
OWNER MAILING ADDRESS: / S.—Flower/Ower
-ev s .f'Y // S
OWNER PROPERTY ADDRESS: 6)Ji/eV'IMOre POO c
(3c
rie,efrt '
OWNER TELEPHONE NUMBER: 1-18-1-1-6 If 77 /3 7
WIS`ei/3" Rob' c— 1
TAX MAP NO. : Section Li 2_. Block -3 Lot /LS
CROSS STREET: 'V Y C 4-0 Si VVe'V' �0+17a4 Mde (
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1� New Existing L�
Residential i/ 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.)
WWI a'a
r 1�
Signature of Applicant
RECEIVED BY: i
T wn CIIrk s rice
eessoved/ y®
DATE: