HomeMy WebLinkAboutHicks ` Town Hall, 53095 Main Road
_' `,' $ P.O. Box 1179
k.S ,:dir i Southold, New York 11971
JUDITH T.TERRY 11
TELEPHONE
['OWN CLERK ` "' ��i� ,o (516)765-1801
REGISTRAR 01-VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT'
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 863-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner HICKS, EVERETT K.
Mailing Address 1 22 SALEM LANE
Mailing Address 2
City St Zip PORT WASHINGTON NY 11050-0000
Property Address 1 PRIVATE ROAD OFF MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 23. 00 block 1 lot 13 . 000
Cross Street WEST OF TRUMANS BEACH
Date Of Last Pump Out 0/00/00
Issue Date: 9/27/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
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OFFICE OF THE TOWN CLERK C,\WF,It.�'- -
Town of Southold c 7: CSG Application No.
Judith T. Terry, Town Clerkf y /
Town Hall, 53095 Main Road / ✓
o PAS x.1z F Residential
P. O. Box 1179 cr3 ;�s`y ' F�,A tri z Non-Residential
Southold, New York 11971 ••&
I
Telephone '�/�i "�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE Seri', 2q/ Iq �►r
OWNER NAME: Eve-ken- K. ICI<S
OWNER MAILING ADDRESS: AA ALES h/-}NE
PO27U) lirN&TDNf N. V. 1 l bS-C)
OWNER PROPERTY ADDRESS: PRI/l/97'E off, ,-).?p ,,v kz,b
Oe , tip/ //957
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section A Block I Lot 1
CROSS STREET: N NE
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: (AM Ce(ZTFtI rl g Y'2S !-
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
DATE:
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