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Home My WebLink AboutHansen i 66 % il �, 4t :'O Town Hall, 53095 Main Road , P.O. Box 1179 - '��►Ai `a®o Southold, New York 11971 74 qr JUDITH T.TERRY ---.,i/.•//0•I 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. 1526-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner HANSEN, ERIC AND CHERYL Mailing Address 1 305 SOUTH WINDSOR DRIVE Mailing Address 2 City St Zip ARLINGTON NIGHTS IL 60004-0000 Property Address 1 405 WILLIAMSBURG DRIVE Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 708-577-3528 /S ©D Tax Map No. section 78.00 block 5 lot ,17.000 Cross Street MAIN BAYV I EW ROAD Date Of Last Pump Out 0/00/00 Issue Date: 9/11/90 Judith T. Terry Southold Town Clerk (TOWN SEAL) • OFFICE OF THE TOWN CLERK c��FFO(,0 =G Town of Southold �� r CQ '_ Application No./s02,4 Judith T. Terry, Town Clerk y Town Hall, 53095 Main Road �: '� =4 ` $10.00 - Residential P. O. Box 1179 u-3 t�� 'r ' •„�. � $25.00 - Non-Residential Southold, New York 11971 O �„ �0 ��` Telephone j , (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. /sib Fee $ /G DATE 92) OWNER NAME: -iJSc i/ �"�� G1, 4-/Uo Cfi&P, - ' J / OWNER MAILING ADDRESS: aJS- //6-rs (conOV OWNER PROPERTY ADDRESS: yO- (A) Lt--s/inc Ate �S/ u; � ( , t/. /l ?7l OWNER TELEPHONE NUMBER: `7o ) S"'2'7- 36- TAX TAX MAP NO. : Section 7 ,,Q, 11--O Block .5-- Lot /7 (Fero CROSS STREET: Mi”/k) 7 i yv/ TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing v 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.) 01" , . J Sign.tur of Applicant RECEIVED BY: Town Clerk's Office DATE: (�++ aJ�n r1\7- \ -�.