HomeMy WebLinkAboutJacobi OFFICE OF THE TOWN CLERK • D
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Town of Southold , Q�
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179 _ a T ,�
Southold, New York 11971 7 Q`® '4'4-";1` �- •�
Telephone 'mg'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 324y Residential X
Fee $ 10.00 Non-Reidential
Septic Cesspool X
NAME OF OWNER: Henry G. Jacobi
OWNER MAILING ADDRESS: 1495 Founders Path
Southold, New York 11971
OWNER PROPERTY ADDRESS: 1495 Founders Path
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-3094
TAX MAP NO. : Section 64 Block 4 Lot ' 16
CROSS STREET: Old Shipyard Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential t
DATE OF PREVIOUS PUMP-OUT: . May 12, 1987
Judith T. Terry -
Southold Town Clerk
DATE.: , July 14, 1987
(TOWN.'SEAL) . F
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OFFICE OF THE TOWN CLERK c0FD(,r�
Town of Southold ���' �Q Application No.
Judith T. Terry, Town Clerk ,g �►
:F; ; ,. .
Town Hall, 53095 Main Road a :' Residential
P. O. Box 1179 - 4. ' Non-Residential
Southold, New York 11971
Telephone 's
i }‘
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /'O
DATE
OWNER NAME: /jE/vR Y 6 LTA C O 7
OWNER MAILING ADDRESS: /9 '5" P'O PA
SOj1>91LD Ar Ar Pen
OWNER PROPERTY ADDRESS: 5,4 M
OWNER TELEPHONE NUMBER: 7‘ 3d D
TAX MAP NO. : Section 6 Block U Lot >6
CROSS STREET: OLD .2i-Ii F yT iW L / /VE
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool I/ New Existing 1
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: , //Jf
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.)
Si at e o Applicant
RECEIVED BY:
Town Clerk's Office
DATE: 9- 7(9 '�1
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