HomeMy WebLinkAboutDelfausse JUDITH T. TERRY ;;' _ :rt Town Hall, 53095 Main Road
TOWN CLERK ® '`" 4 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS @it � R ,: a �• Southold, New York 11971
MARRIAGE OFFICER � �t�" Fax (516) 765-1823
�0-e Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1817-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DELFAUSSE, LYNNE
Mailing Address 1 1355 NEW SUFFOLK AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1355 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8799
Tax Map No. section 114.00 block 11 lot 27.000
Cross Street OLE JULE LANE
Date Of Last Pump Out 10/00/87
Issue Date: 12/04/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK sc�OMA'
Town of Southold • ea = Application No. l
Judith'T. Terry, Town Clerk y
f ;
Town Hall, 53095 Main Road cn �. -L $10.00 - Residential /d
P. O. Box 1179 '" '=-' $25.00 - Non-Residential
�'- ,�
Southold, New York 11971 � 0� e
Telephone : .( s
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
for .
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE Aljll�v‘LKr 30 (qv
• OWNER NAME: h h„
OWNER MAILING ADDRESS: /35-5- Vial") Sin-(F Ik �trthu
• �Q I/ ��af�l� �f �/
_OWNER PI?OPERTY_ADDRESS __ . 5�i_►.n P^ _- - - - -
OWNER TELEPHONE NUMBER: Z(o 02.9g _ 87c1
TAX MAP NO. : Section ( / 1 Block 1/ Lot ()Ia.7
CROSS STREET: 6/c J04, LQ yr
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New ; Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Oct: -" /7$7
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.)
cLd
dill Signature of Applican
RECEIVED BY:
Town Clerk's Office .
DATE:
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