HomeMy WebLinkAboutJackson (2) JUDITH T. TERRY , Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
"�' 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. 1793-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JACKSON, WALTER
Mailing Address 1 P. O. BOX 845
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1175 VILLAGE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9427
Tax Map No. section 114.00 block 6 lot 13.000
Cross Street ROUTE 25/NORTH ROAD
Date Of Last Pump Out 0/00/00
al".1 0„ipiePOVA":°1_,r117,
Issue Date: 10/16/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK oS�FFD(,- =
Town of Southold CQG' Application No.
Judith T. Terry, Town Clerk ,.. i •
Town Hall, 53095 Main Road ~ � -� $10.00 - Residential
P. O. Box 1179 ` �,�� $25.00 - Non-Residential
Southold, New York 11971 O ® O� ��•
Telephone * ,IA" 1.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $ /0
DATE /f3/9i
OWNER NAME: E/L
OWNER MAILING ADDRESS: /( 7 5 lily (-E4 c C= /v' e- p V-6
7-7 ft I(9,c-
OWNER PROPERTY ADDRESS: 1 ( 7 g f
OWNER TELEPHONE NUMBER: £ (� - L c( `c—
TAX MAP NO. : Section ! I d Block Lot /3
CROSS STREET: (g S /fr
TYPE OF SYSTEM: Septic Tank
New Existing
Cesspool ' New ExistingK i'I
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 road.)
6-)
Si of Applican
RECEIVED BY: be
Nedrler
„ k's Office
DATE: OCT I
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