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Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ®� TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OI•VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 850-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner ESPENSEN, BORGE
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Mailing Address 1 1255 WOODCLIFF DRIVE
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Mailing Address 2
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City St Zip MATTITUCK NY 11952-0000
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Property Address 1 1255 WOODCLIFF DRIVE
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Property Address 2
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City St Zip MATTITUCK NY 11952-0000
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Owner Telephone No. 516-298-4172
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Tax Map No. section 107. 00 block 6 lot 18. 000
Cross Street WESTVIEW DRIVE
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Date Of Last Pump Out 0/00/83
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Issue Date: 9/20/88 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
i
OFFICE OF THE TOWN CLERK
Town of Southold 0�� CQG Application No. �5 d
Judith T. Terry, Town Clerk y ��
Town Hall, 53095 Main Road -< Residential
P. 0. Box 1179 cnNon-Residential
Southold, New York 11971
Telephone ®( y►��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
, 'J
!APP" LICATI"ON'
for
OPERATION PERMIT
SEPTIC TANK I or CESSPOOL
Operation Permit No.
Fee $ /b_
DATE September 19 , 1988
r _ ,
OWNER NAME: Mr. Borge Espensen
OWNER MAILING ADDRESS: 1253 Woodcliff Drive ,
Mattituck, NY 11952,
OWNER PROPERTY ADDRESS: Same as above ;7
OWNER TELEPHONE NUMBER: 515-298-4172 +
y TAX MAP NO. : Section / 0 Block Lot
CROSS STREET: Westview Drive
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool g New Existing g
Residential , X Non-Residential
DATE OF PREVIOUS PUMP-OUT: l 9 �- 3
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.)
9 natuV61 Applica t
RECEIVED BY:
REC VETown Clerk's Office
DATE:
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Town Clerk Southold
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