HomeMy WebLinkAboutEdstrom ,,0. la
JUDITH T.TERRY ; ® w' tL�� 3 Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
REGISTRAR OF VITAL STATISTICS < . 1� Southold,New York 11971
MARRIAGE OFFICER �� a 0 / Fax(516)765-1823
RECORDS MANAGEMENT OFFICER gi is4;of Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER .����,,,••��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3415-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner EDSTROM, JANE
Mailing Address 1 945 NEW SUFFOLK AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 945 NEW SUFFOLK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5316
Tax Map No. section 114.00 block 11 lot 23.000
Cross Street MAIN ROAD
Issue Date: 12/06/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �FFU`
Town of Southold , �� �C�� Application No. ��`r
Judith 'T. Terry, Town Clerk Z` . �'`� $10.00 - Residential
Town Hall, 53095 Main Road
P. 1/-
o. Box 1179 cn . i ;' $25'.00 - Non-Residential
Southold, New York 11971 O �$
Telephone Q( ,k `W' I.
(516) 765-1801
TOWN OF SOUTHOLD
, SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
'OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10;00
DATE 12/2 /05-
OWNER
2/2 / 05-
OWNER NAME: 7-aLe c s+ roi
OWNER MAILING ADDRESS: Ci 145 New 7( cfo I k Ave__
k I\).y 116152-
OWNER
1q52-
OWNER PROPERTY ADDRESS; Saj°I'ie
OWNER TELEPHONE NUMBER: 2.q 5 31 to or- 20S-5527
TAX MAP NO. : Section .t'P Block Lot .7_3
CROSS STREET: -
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential X Non-Residential
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.)
4 '/ Ecie2
S ;nature of Applicant
RECEIVED BY: RER �g
` Ierk's Office
DATE: DEC 61995
Town Cie* Southold
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