HomeMy WebLinkAboutHaase nur
°,�* i% Town Hall, 53095 Main Road
• \ '� P.O. Box 1179
��. � �!�� Southold, New York 11971
� TELEPHONE
JUDITH T.TERRY ` !.
TOWN CLERK ! �/[L/�` (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. 869-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HAASE, ROBERT J.
Mailing Address 1 P. O. BOX 1
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 8620 MAIN ROAD ,
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-0793
Tax Map No. section 31. 00 block 7 lot 5.000
Cross Street BAY AVENUE ,
Date Of Last Pump Out 0/00/00
Issue Date: 9/30/88 Judith T. Terry
Southold Town ,Clerk ,
(TOWN. SEAL) ,
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OFFICE OF THE TOWN CLERK IcvFFOC,(, �
Town of Southold �� Y �� Application No.
Judith T. Terry, Town Clerks
Town Hall, 53095 Main Road � � � C } Residential
p. O. Box 1179 ' �' Non-Residential
Southold, New York 11971 •p' X.Qt;
Telephone ®.� 4 Ni‘
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- nor
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE KIM 2.3 � i 1r
•
OWNER NAME:
OWNER MAILING ADDRESS: pQL7,OX
c_cAs-+- ma in'cc 11.g 3 ci
OWNER PROPERTY ADDRESS: 8(2,0 MO\1 rm7 ( C'
M-a v-ioM lG 39
OWNER TELEPHONE NUMBER: SJ, , - y-)') - o'i 3
TAX MAP NO. : Section 3 \ Block / Lot
CROSS STREET:' ,
TYPE OF SYSTEM: ' Septic Tank. New Existing
Cesspool t.77 New Existing
Residential V/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: ��
LOCATION MAP: Must be attached hereto, before permit may be issued.
(Locate building and system; give northarrow and feet
of distance, approximately, to building'and closest road.)
Signature of : pplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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