HomeMy WebLinkAboutHendrickson OFFICE OF THE TOWN CLERK ' ic0FUCkC
Town of Southold , Qz - O�
Judith T. Terry, Town Clerk : ';
Town Hall, 53095 Main Road ` > t
P. O. Box 1179 � s � y, �$
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 449 Residential X
Non-Residential
Fee $ 10.00 '
Septic Cesspool X
NAME OF OWNER: Myrtle Hendrickson
OWNER MAILING ADDRESS: 2055 Calves Neck Road
Southold, New York 11971
OWNER PROPERTY ADDRESS: 2055 Calves Neck Road
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-2175
TAX MAP NO. : Section 70 Block 4 Lot 45
CROSS STREET: Harper Road
TYPE OF SYSTEM: Septic Tank New . Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
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Judith T. T ry
Southold Town Clerk
DATE: September 30, 1987
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(TOWN SEAL) )
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OFFI6 F THE TOWN CLERK c,\FFO(A�'-
Town of Southold 0�4 - _CQG% Application No. 6,y6Judith T. Terry, Town Clerk . ,t
Town Hall, 53095 Main Road • ' i'"_ ..4. Residential
P. O. Box 1179 ;®4 ` i ' Non-Residential
Southold, New York 11971 O t ' ,��
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Telephone : / 4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
.
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /b
DATE d S,91- / /co 7
OWNER NAME: t'KJ G & 7---/E,y7 /G 4/56 j/
OWNER MAILING ADDRESS: 5 C,9LJ/,c 4/6C if-
9GT LJ/ /'O l__.J /1J v
OWNER PROPERTY ADDRESS: S f}/y
OWNER TELEPHONE NUMBER: 5/ 6 7 65" 2-7 7S
TAX MAP NO. : Section 70 Block 7 Lot Li S--
CROSS
CROSS STREET: t/19 R {�e4 PO
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing
Residential V 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.)
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'1 ignature o Ap,r ant
71.
RECEIVED BY: eI,� c
�'F_ ?"'own Cl irk's Off ce
DATE: SEP 301997
Town Clerk Southold
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