HomeMy WebLinkAboutGallagher OF S�j.
Edr1E ETE A.NEVUAoZ �d Town Hall,53095 Man Road
TO"CLQ P.O.Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New►York 11971
MAXRIJ4G$OFFICER Fax(631)786-6145
RECORDS DdANI1T,F8IrLENT OFFICER Telephone(681)786-1800
FREEDOM OF INFORMATION OFFICER eoutholdtown.northfork.aet
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4375-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner GALLAGHER, DENNIS & RITA
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Mailing Address 1 42 WELLS ROAD
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Mailing Address 2
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City St Zip GREENLAWN NY 11740-0000
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Property Address 1 3140 MINNEHAHA BLVD
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-000-0000
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Tax Map No. section 87.00 block 3 lot 40.000
Cross Street
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Issue Date: 9/23/08 Elizabeth A. Neville
------ Southold Town Clerk
(TOWN SEAL)
• o�osuFFo�,��,
ELIZABETH A. NEVILLE y� Town Hall, 53095 Main Road
TOWN CLERK y Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICS OSouthold, New York 11971
MARRIAGE OFFICER A • ��� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �Ol �►� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10K or Non-Residential @ $25 Application No.
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Permit No.
Owner Name Dann,i 5
Owner Mailing Address O L
Owner Property Addre
nnye
Owner Telephone No. lw P e►n I Q L vv\
Tax Map No: Section Block _ Lot _
Cross Street
Please check each that applies: New Construction
Alteration to Existing System
Residential. 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.)
J'2 .,0_,_ 1 c?
Signature of Appl cant Dake
Received by: �2)
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