HomeMy WebLinkAboutHagerman k r Town Hall, 53095 Main Road
$ P.O. Box 1179
,��z2., � .• �! Southold, New York 11971
JUDITH T.TERRY
N-÷7/701 `�s �'�• 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. 780-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HAGERMAN, KENNETH
Mailing Address 1 BOX 1176
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 PARKWAY
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3023
Tax Map No. section 70. 00 block 11 lot 14.000
Cross Street PINE NECK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/09/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK = ViSf FO(,(�"'• '.
Town of Southold %ir > CQG Application No. 7�
Judith T. Terry, Town Clerk .�'` %r "%4__z -
� Y��$ �:--;;PV, 7 Residential • �/
Town Hall, 53095 Main Road
P. O. Box 1179 cn � ` ' �` Non-Residential
Southold, New York 11971 O"®,. ' '�`�
Telephone 70 Ad Y► •'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT ,
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ( 9
DATE
OWNER NAME: C' / t. t r 4; r LJ / /
OWNER,MAILIN ADDRESS: Ul-e9 tl 2/6
, 0 e, -r Fie 4-1.9 by
-OWNER ,PROPERTY ADDRESS: - CcCQ> /
'/' OWNER TELEPHONE NUMBER: 26(C-5 O 2'3
1.
TAX MAP NO. : Section 7.O Block // Lot `
CROSS STREET: Li2e. 71 J _ x0,,,?,
TYPE OF SYSTEM: Septic Tank New Existing
'
Cesspool L.----- New Existing C...-.-----
Residential L Non-Residential
DATE OF PREVIOUS PUMP-OUT: It
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.)
' S,-eia;l2-414, ( " (//4"0----
Signature of Ap Iicant
RECEIVED BY -
Townger �c '
k's O fice
RECEIVED
DATE:
AUG 0 9 ISMM.
down Clerk Southold
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