HomeMy WebLinkAboutHallock 8 z Town Hall, 53095 Main Road
I 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. 667-R Residential X Non-Residential
Fee $ 10. 00 Septic X Cesspool
New Existing X
Name Of Owner HALLOCK, SUSAN
- Mailing Address 1 P.O. BOX. 200
City St Zip PECONIC NY 11958-0000
Property Address 1 WELLS ROAD
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-1249
Tax Map No. section 8.6. 00 block t2 lot/2.7o000
Cross Street MAIN ROAD (ROUTE 25)
Date Of Last Pump Out 0/00/00
/s
Issue Date: 4/07/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK _. gFi(ir
Town of Southold Application No. C 7
Judith T. Terry, Town Clerk s t ;iva ‘., Residential
Town Hall, 53095 Main Road ` y*x
P. 0. Box 1179 ` } ` ' Non-Residential
Southold, New York 11971k. ,
*IA'
,< $
Telephone o.� 0I.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. �4 7
Fee $ /D
DATE 1a.,,,' ( - 8b
OWNER NAME: Elti AIV
OWNER MAILING ADDRESS: , Qt bX Roo
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OWNER PROPERTY ADDRESS: \AJL—'LLS Icp
QNe_(S7( )
N '`OWNER TELEPHONE NUMBER: J �� - l 4Cj ?4 _.2,-42. 7
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TAX MAP NO. : Section 06 Block Lo/ ,
CROSS STREET: fr fer, NJ) c_ °N \ I I c 0
TYPE OF SYSTEM: Septic Tank I New / Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS. PUMP-OUT: �3-
LOCATION MAP: Must be attached hereto efore permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.) •
OtANA / /
Signature of Applicant
RECEIVED BY: _ / ,;�
Town !erk's Of' ice
DATE: °y /7- /Y
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