HomeMy WebLinkAboutHelgeson JUDITH T.TERRY �,1 '; Town Hall,53095 Main Road
TOWN CLERK =s: g P.O.Box 1179
; ,� 0 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER : # ��� � ( )765-1823
RECORDS MANAGEMENT OFFICER _� Fax 516
®� ���dl Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER go"
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3291-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of-Owner HELGESON, JOHN O.
Mailing Address 1 205 SUMMIT DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 205 SUMMIT DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3911
Tax Map No. section 79.00 block 6 lot 16.000
Cross Street ED'S ROAD
Issue Date: 12/12/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 5�1FFQLK
Town of Southold �� e& ---
Town Application No. meq/
Judith T. Terry, Town Clerk �� '1 $10.00 - Residential
Town Hall, 53095 Main Road . '
P. O. Box 1179 to _ , • ��' $25.00 - Non-Residential
Southold, New York 11971 O ' 0*��`
Telephone _0.� . 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE k 2 8 —o1,1
OWNER NAME: JoH3 e0 - \EDGES• a�
OWNER MAILING ADDRESS: -Z.. 06- Su Kvr- �x,
0L-9 ‘\=11-\
OWNER PROPERTY ADDRESS: ,^„a
OWNER TELEPHONE NUMBER: `Z 6 a' -zq jl
TAX MAP NO. : Section -1,g t-6,Block ( Lot (-
CROSS STREET: C• Ebs Z !/Vle-nsek�'k_ r uutvo, j
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing y
Residential Non-Residential
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.)
\<\.,-Q %0,--------- ,
S\ nature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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