HomeMy WebLinkAboutBreen VERA
,t. ® 0ATown Hall 53095 Main Road
JUDITH T.;'TERRY �, ,
TOWN'�LERK �r P.O. Box 1179
REGISTRAR OFWITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER C) IFax (516) 765-1823
4 *P)i�!' Telephone (516) 765-1801
uj EDOFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1881-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner BREEN, WILLIAM J.
Mailing Address 1 1615 MASON DRIVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1615 MASON DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6916
Tax Map No. section 1 .04 block 6 lot 18
Cross Street BROADWATERS ROAD
Date Of Last Pump Out 0/00/00
0
Issue Date: 4/14/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
b,i
a--'OFFICE OF THE TOWN CLERK .S\\FFD(,r
�®
Town of Southold j < 06' Application No. /S-�' /
Judith T."Tewry, Town Clerk .� �"
Town Hall, 53095 Main Road a s ` � $10.00 - Residential
jp. O. Box 1179 u' " ; ti%* ` 1 `'
$25.00 - Non-Residential
Southold, New York 11971 O i
Telephone : .( 44
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /M
Fee $ /O �
DATE 0%342
OWNER NAME: w v°�- V 1 / 4
OWNER MAILING ADDRESS: /‘/� f-12 /9"-V71/
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7j
TAX MAP NO. : Section /a Block la" Lot
CROSS STREET: (et
TYPE OF SYSTEM: _ Septic Tank New Existing
Cesspool (/ New v Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ° ( D A_
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 of pplicant
RECEIVED BY: C (L)/(--(24-<,
own Clerk's Office
DATE: />/ ��
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