HomeMy WebLinkAboutHansen (2) '"11« Town Hall, 53095 Main Road
P.O. Box 1179
r4�®�! Southold, New York 11971
JUDITH T.TERRY ;=�, �,/ 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. 1162-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HANSEN, ERIK AND CHERYL
Mailing Address 1 305 S. WINDSOR DRIVE
Mailing Address 2
City St Zip ARLINGTON HEIGHTS IL 60004-0000
Property Address 1 WILLIAMSBURG DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 312-577-3528
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: 6/19/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
S.y
1111
OFFICE OF THE TOWN CLERK ,.�C315g /U' '_ //� L
Town of Southold �V ' k.. Application No.
Judith T. Terry, Town Clerk .` t�'"' � S y
Town Hall, 53095 Main Road ` - $10.00 - Residential
P. O. Box 1179 tri ` ' ' :'
$25.00 - Non-Residential
Southold, New York 11971 O
Telephone _ .( Y►
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /b•'
DATE 6 - //- 77
OWNER NAME: 6 p,�je ileith C ti'r, /�
/ 1-/ N"scal/
OWNER MAILING ADDRESS: jos- w���IQS'd�2 e (UF
OWNER PROPERTY ADDRESS: Lc)ll,Li/4-01s,6d4C,- ke.1v�'
c) crr7 o 44 4/, 9/- //9I,/
OWNER TELEPHONE NUMBER: 3/g -- 677- 3,_c- `5)
TAX MAP NO. : Section 7 $ Block S Lot / 7
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ,�� New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permi_t__ma_y be issued. _ _
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
.a e
Si nature of Applicant
RECEIVED BY:
Town Clerk's Office
E EA ED
DATE:
.01119-C.--
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