HomeMy WebLinkAboutHubbard (3) OFFICE OF THE TOWN CLERK • •c.` FOC/-
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Town of Southold 'f� �G
Judith T. Terry, Town Clerk -
Town Hall, 53095 Main Road
P. O. Box 1179 v `' `
Southold, New York 11971 p `c- •
Telephone ss-ss---WO, , st►%6
(516) 765-1801 - -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
Operation Permit No. 612 Residential X
Non-Residential
- Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Junius Hubbard
OWNER MAILING ADDRESS: P.O. Box 785
Mattituck. New York 11957
OWNER PROPERTY ADDRESS: Main Road
Mattituck, . New York 11957
OWNER TELEPHONE NUMBER: 516-298-8852
TAX MAP NO. : Section 122 Block 6 Lot 1,e' /4
CROSS STREET: Factory Avenue and Sigsbee Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Ter
Southold Town Clerk
DATE: February 16, 19RR - -_-
•
-(TOWN SEAL)
OFFICE OF THE TOWN CLERK `4-C��FF�(i'°'=
Town of Southold ��O <, CSG. Application No.
Judith T. Terry, Town Clerk ' '' e., < ) Residential
Town Hall, 53095 Main Road . ,
P. O. Box 1179 u' <f O Mi ; Non-Residential
Southold, New York 11971 4 •:.P.'=` *-$
Telephone .! 0
•
(516) 765-1801 �,�
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
• for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. ( )---d
Fee $ •
4 DATE - , /G / Ct k,,P
OWNER NAME: JUn8ILS V1LJ 10;}e,c
OWNER MAILING ADDRESS: P. ® e Iia x 1785
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OWNER PROPERTY ADDRESS: k-d t.3 RCA .
KA. rri.LC-tom1 1\I, l t q�-._,.7
OWNER TELEPHONE NUMBER: 5 t 0 ' ,248 . .8852_
TAX MAP NO. : Section /O� O-- . �;__ Block 6j 6Lot s
CROSS STREET: /a-CiRli Aug . it Oji Lac bee. -Rdl
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool t-------- New Existing 4--------
Residential 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 Toad.)
i
j4Signature of Appli
RECEIVED BY: _
Town C rk's Off ee
DATE: 4- - 6' - etd"
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