HomeMy WebLinkAboutEsslinger Town Hall, 53095 Main Road
r y P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ✓® TELEPHONE
TOWN CLERK (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. 866-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner ESSLINGER, JEAN G.
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Mailing Address 1 P. O. BOX 172
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property- Address 1 1515 ARSHAMOMAQUE
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 516-765-2028
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Tax Map No. section 66. 00 block 3 lot 11. 000
Cross Street HIPPODROME DRIVE
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Date Of Last Pump Out 0/00/00
,
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Issue Date: 9/28/88 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold O�Q CSG Application No. �� 6
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -< Residential
P. 0. Box 1179 v' Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: C ; A
OWNER MAILING ADDRESS: -
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: �rp
TAX MAP NO. : Section I , Block Lot i
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
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.)
Signature of Applican
RECEIVED BY:
Town Clerk's Office
DATE:
�S�tQOh d Fs,rjq dL AvP
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