HomeMy WebLinkAboutHairston 001(tZS
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Town Hall, 53095 Main Road
$ P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY �i �r � 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. 1228-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HAIRSTON, VIRGINIA
Mailing Address 1 1825 CARROLL AVENUE
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 1825 CARROLL AVENUE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-2627
Tax Map No. section 74.00 block 3 lot 10.000
Cross Street COUNTY ROAD 48
Date Of Last Pump Out 0/00/87
Issue Date: 8/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK CO Fair
Town of Southold •® CSG•, Application No. /29
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road " "As.L- -< $10.00 - Residential
P. O. Box 1179 En " ' a �
� �. �� :,�: � $25.00 - Non-Residential
Southold, New York 11971 O ®„• $'':
Telephone •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ //J,
DATE i /AP?.
OWNER NAME: / �j
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OWNER MAILING ADDRESS: /(g,5--
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OWNER
(c OWNER PROPERTY ADDRESS 4 6 <1' ( x' -
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OWNER TELEPHONE NUMBER:, ._ ( ,0 7
TAX MAP NO. : Section / 4 Block 3 Lot /0
CROSS STREET: C eqr
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7 r
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.)
/ignatureoT Applicant
RECEIVED BY: A
own Clerk's Office
DATE: /�-
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