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HomeMy WebLinkAboutHanson t `�' Town Hall, 53095 Main Road Ov P.O. Box 1179 ,ss22� �'®��� JUDITH T.TERRY Southold, New York 11971 ®2 `�-S ri-!1i FAX(516)765-1823 TELEPHONE(516)765-1801 TOWN CLERK 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. 969-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner HANSON, ARTHUR G. Mailing Address 1 P. O. BOX 994 Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 2405 BAY AVENUE Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 516-298-4254 Tax Map No. section 144.00 block 4 lot 6.000 Cross Street MAIN ROAD & PECONIC BAY BLVD Date Of Last Pump Out 0/00/82 Issue Date: 12/23/88 Judith T. Terry Southold Town Clerk (TOWN SEAL) • • OFFICE OF THE TOWN CLERK — cAFFO( • '- Town of Southold �� - CQG' , Application No. Judith T. Terry, Town Clerk �� y Town Hall, 53095 Main Road _ h 7 pLisResidential P. O. Box 1179 � _` -3. i ; Non-Residential Southold, New York 11971 4 ® �o��� Telephone = .� 't (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ DATE f i * OWNER NAME: 4741111,1,r //,j, 5 0/1/ OWNER MAILING ADDRESS: P- 0, B OY 6194 li�-r<i (:Ltc,k 1�� y• 11 q-2, OWNER PROPERTY ADDRESS: o/ ©t- Bi3i.y Al ig lfc- ii• y OWNER TELEPHONE NUMBER: ci f e� 2 TAX MAP NO. : Section 141/' Block Lot C0 CROSS STREET: (V)fti,, 4 (2tAs) GL P�.i 0 Za .- TYPE OF SYSTEM: Septic Tank New Existing Cesspool V' New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: /611®U _- 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.) Signature of Applicant RECEIVED BY: , • Town Clerk's Office MEM DATE: DEC 2 (31988 town Schi' 08� 140 t, s .