HomeMy WebLinkAboutThirlby, Ted o�OSUFf®(�c
ELIZABETH A.NEVILLEo y1 Town Hall, 53095 Main Road
TOWN CLERK eta P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O A Southold, New York 11971
Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATERDISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential' ' or Non-Residential @$25 'Application No.
Permit No.
Owner Name d 2-77,rI
Owner Mailing Address SO On Oe c J i VA
Owner Property Address SPM 2 A G
Owner-Telephone No.
Tax Map No: 1600 Section 054 Block Lot T
Cross Street nQ -Dr)L.,
Please check each that applies: New Construction
Alteration to Existing Sy_stem
Residential X Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to-building
and closest road. New construction may submit copy of survey with SCHD approval) S'QV_ QV-Qi`' _
Ignature of Applicant Date
Received by:
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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4497-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner TED THIRLBY
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Mailing Address 1 11185 SOUNDVIEW AVE
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 11185 SOUNDVIEW AVE
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 631-765-2396
Tax Map No. section 54:00 block 5 lot 39.000
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Cross Street RENE DRIVE
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Issue Date: 1/17/17 Elflabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)