HomeMy WebLinkAboutDickerson (3) Ohl kir
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04 Set 4 W.0
Town Hall, 53095 Main Road
P.O. Box 1179
r__401, 1.) i° Southold, New York 11971
JUDITH T.TERRY 0.0 FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1030-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DICKERSON, EARLE & VIRGINIA
Mailing Address 1 P. O. BOX 992
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 WESTPHALIA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4148
Tax Map No. section 114.00 block 10 lot 21 .000
Cross Street DEER DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 0Q�3IFai
Town of Southold . -- ` CQ ' Application No. 7O'3 )
Judith T. Terry, Town Clerk ,.;4# \ter %
Town Hall, 53095 Main Road a F 1 Residential
P. O. Box 1179 cn `' ti_,r "3f Non-Residential
Southold, New York 11971 vb.
•
Telephone _ : j � •
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(516)- 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /p•
DATE // f�
• OWNER NAME: F4 P ,� Vif /WM- 13 v./F:\ 4,
2
OWNER MAILING ADDRESS: Fel B o clop,
i''1ft`F-771—CJ N y
OWNER PROPERTY ADDRESS:\ )i STPhq 11/ 6 9d
prl 0-TT/ -t-)C K //
OWNER TELEPHONE NUMBER: 3417 —44/ �� {
TAX MAP NO. : Section 1 / / Block /0 Lot
CROSS STREET: -e5T 4.Iia Rc
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Jan, g l Jp6i� ���Q'd y? l rPCcI \) -16-46.
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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.)
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Signature of Applicant
RECEIVED BY: G'�
Town C rk's Of ice
DATE: V/077-
FEB 2 2 NH4
Tom C.) ,,oaf .