HomeMy WebLinkAboutHassildine 04
r' "„" Town Hall, 53095 Main Road
P.O. Box 1179
..� 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. 1270-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HASSILDINE, EDWARD C.
Mailing Address 1 2505 WEST CREEK AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2505 WEST CREEK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6546
Tax Map No. section 110.00 block 5 lot 5.000
Cross Street WEST ROAD/DICKS POINT ROAD
Date Of Last Pump Out 7/00/80
Issue Date: 10/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ''' �UFFDi
Town of Southold COG Application No. /3.-;i6�� ,
Judith T. Terry, Town Clerk • ", ,
Town Hall, 53095 Main Road ~ "8a�" -�•� $10.00 - Residential
ins
p. 0. Box 1179 �'"t •
s ��,���`,� � $25.00 - Non-Residential
Southold, New York 11971 O '® 3= o �••
Telephone( 1‘
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
For
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE efo v 3o /c7 c/
OWNER NAME: ED tit. leo C , /155 L.1p9,J
•
OWNER MAILING ADDRESS: ZSO 5 d.'JCS i cizeew Ave
Vrcift9 &v1_7_-• N°• 7', A/ / 3.s-
OWNER PROPERTY ADDRESS: 5 {M &
OWNER TELEPHONE NUMBER: 7 341-
TAX
41-TAX MAP NO. : Section 1/ 0 Block Lot cs
CROSS STREET: I4JEST ) JD. ; bICWS PT, Ri
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool /7 New Existing
Residential t✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: .J G,l� / 60
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.)
•
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C Istlet4,,,JeL_QL
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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