HomeMy WebLinkAboutHorton (2) JUDITH T. TERRY z Town Hall, 53095 Main Road
TOWN CLERK 0 T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS UI �• Southold, New York 11971
MARRIAGE OFFICER , �. ," Fax (516) 765-1823
-�`® a�® ��' 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. 1649-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HORTON, R. DUANE AND ADA
Mailing Address 1 3145 WELLS ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 3145 WELLS ROD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-3259
Tax Map No. section 86.00 block 2 lot 6.000
Cross Street ROUTE 25
Date Of Last Pump Out 6/26/78
Issue Date: 4/05/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •cvVFQ(,I+ =
Town of Southold % CSG Application No.�� (7/ ;'
Judith T. Terry, Town Clerk . -
Town Hall, 53095 Main Road
$10.00 - Residential
P. O. Box 1179 u' tslAti $25.00 - Non-Residential
Southold, New York 11971 O O��`�
Telephone (// A-••
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /D'
DATE �,eei/? 7 , /
OWNER NAME:/& ',1AJC /2, i / )176,ov./
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OWNER MAILING ADDRESS: 4� GIJfLLZ �l
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: `16 c 34S
TAX MAP NO. : Section U) Block °W.J Lot
CROSS STREET:
TYPE OF SYSTEM: Septic.Tank . New Existing
Cesspool New Existing 1C
• Residential j Non-Residential
DATE OF PREVIOUS PUMP-OUT: (p-' --
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 ffice
DATE:
WAR 1 51991
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