HomeMy WebLinkAboutDickerson 04
+'o Gym;
y Town Hall, 53095 Main Road
`rQ �-�� P.O. Box 1179
v.,••• Southold, New York 11971
JUDITH T.TERRY >.�,,,,,,i" FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1542-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DICKERSON, GLADYS
Mailing Address 1 BOX 1426
Mailing Address 2 MAIN ROAD
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8783
Tax Map No. section 115.00 block 2 lot 6.000
Cross Street CARDINAL DRIVE
Date Of Last Pump Out 5/00/85
Issue Date: 10/02/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
_ .J • •..
OFFICE OF THE TOWN CLERK .c\ WFU(,r�'-
Town of SoutholdC'W•21.= Application No.
Judith T. Terry, Town Clerk . ;' v
%1 $10.00 - Residential
Town Hall, 53095 Main Road -{ & .
P. O. Box 1179 u' i�yrY wt ; $25.00 - Non-Residential
Southold, New York 11971fito r J
Telephone j
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ �� 1
DATE /f 4 7`-' w �?7O
'OWNER NAME: Ar)
[/
OWNER MAILING ADDRESS: d l/ , 7272.1,2110'
Y47t. � ,)1.• 1fClc;��
OWNER PROPERTY ADDRESS: � Jj� £ f
. //Q$
OWNER TELEPHONE NUMBER: ow, Q 7& o7,5741
TAX MAP NO. : Section ,i/S- Block Lot lU
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
• Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,21 6 q �
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.)
/i. di"
/ Sigvature of Applicant
RECEIVED BY:
Turin Clerk's Office
RE
-DATE: 0c +4
SEP 27
Town Cie* SAath010