HomeMy WebLinkAboutHilsenbeck JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
- REGISTRAR OF VITAL STATISTICS �` Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER ® ®���
,y®1 �� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3102-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HILSENBECK, WALTER C.
Mailing Address 1 570 CRITTENS LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 570 CRITTENS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2655
Tax Map No. section 70.00 block 12 lot 13.000
Cross Street PINE NECK ROAD
Date Of Last Pump Out 0/00100
Issue Date: 8/18/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFPItE OF THE TOWN CLERK c31F�(
Town of Southold OHO ; .-, .„I'4 . --- Application No. b/0--�,
Judith T. Terry, Town Clerk . P... ' a: : s �`'1 $10.00 - Residential `—
Town Hall, 53095 Main Road y-
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P. O. Box 1179 crs `'v��, `-- , `' $25.00 - Non-Residential
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Southold, New York 11971 O `®; r- . ..'
Telephone -V.( •* 1�O
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • .
DATE
OWNER NAME: al/17'X ,7G n ,i, /v8e-aL‹./
OWNER MAILING ADDRESS: j Art, E A s a -EL_c w
OWNER PROPERTY ADDRESS: ,la CiC1/ d i4' AY-qN'
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OWNER TELEPHONE NUMBER: ' 714---- ,az -4.---
TAX MAP NO. : Section � Block /A, Lot la
CROSS STREET: 737/. _ %re, AV
TYPE OF SYSTEM: Septic Tank (/' New Existing ✓
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Cesspool ' New Existing
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Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: ? /2 —77/7/15-J
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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• Signature of Applicant
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RECEIVED BY: (../C141-4--------
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Ilk own Clerk's Office
DATE: ef 7
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