HomeMy WebLinkAboutDixon JUDITH T. TERRY � " � 'Oa : Town Hall, 53095 Main Road
TOWN CLERKoffrn
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS : ® _ n� ` r _ Southold, New York 11971
MARRIAGE OFFICER ` E2 Fax (516) 765-1823
i;ir , Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1723-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DIXON, ANNE TERRY
Mailing Address 1 P. O. BOX 6
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 375 JOCKEY CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3788
Tax Map No. section 70.00 block 2 lot 16.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/84
Issue Date: 7/12/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFIC,E0016.:'TI"IE TOWN CLERK �c3vFFair
' Town of Southold ‘,4 4 .„, ,-CQG Application No. /702
Judith T. Terry, Town Clerk % ,
Town Hall, 53095 Main Road - �`} $10.00 - Residential v
P. O. Box 1179 crst�; �; $25.00 - Non-Residential
Southold, New York 11971 4 > _ --/
Telephone -..0 '' '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ?b
I
DATE 7 i6 / 1 l j
OWNER NAME: — r; .------' s
OWNER MAILING ADDRESS: iQ 6 t 6
u _ ' AL ;vo �. .__ 1 -1100C3
OWNER PROPERTY ADDRESS: 5- 4-1--(1)C/ C ' Jc., b1 cfi'k.�
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1N7/ �j ctU C
OWNER TELEPHONE NUMBER: SIC - 7( Jam` 37 3'
ix MAP NO.� Section -76 Block Lot / C
CROSS STREET: pix} 6c1) GR .,5)
TYPE OF SYSTEM: Septic Tank New Existing
,?jesspool New Existing
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: ' l Try
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.)
-5€"' -- /1-11-Pd?
Signature of A.plicant
RECEIVED BY: 4.,..„,_a (2
Town GCIerk's ffice
DATE: ,.., ^';
JUL 11. 1991
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