HomeMy WebLinkAboutErickson \. fit 7 m
Oil for I 0,0
T \
ti \ Town Hall, 53095 Main Road
� P.O. Box 1179
.� V0 Southold, New York 11971
JUDITH T.TERRYi./$1`° 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. 1443-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ERICKSON, WALTER SR.
Mailing Address 1 2950 MINNEHAHA BOULEVARD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2950 MINNEHAHA BOULEVARD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2574
Tax Map No. section 87.00 block 3 lot 42.000
Cross Street OPECHEE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
_ • /z/ L/3
OFFICE OF THE TOWN CLERK ,���'
Town of Southold QcJVFFO({, . . f)31; Application No.II
Judith T. Terry, Town Clerk $10.00 - Residential
Town Hall, 53095 Main Road �' :'�
p, O. Box 1179 cry { �t1� r �
;;. $25.00 - Non-Residential
Southold, New York 11971
Telephone _Ql . `�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE y/a/ / p "
OWNER NAME: WAZ- 7 E / lc/< 5 ,
OWNER MAILING ADDRESS:"-2 7(ro
S o vl'/7l0 l)re, dl 2 7/
OWNER PROPERTY ADDRESS: Ag61.0 psrig /( /M- d//4' 4 k,A
OWNER TELEPHONE NUMBER: 76'5- A(5•'2
TAX MAP NO. : Section ! Block Lot yc-
CROSS STREET: 11`2:Y
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing G�
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
911crlIon) ace-4--"J
Signature of Ap icant
RECEIVED BY: ,
Town Clerk's Office
DATE:
1
6(
w ,
�/0 '