HomeMy WebLinkAboutJacobi (2) ..i.: ..-
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Cr3 Town Hall, 53095 Main Road
P.O. Box 1179
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Southold; New York 11971
/0"°° TELEPHONE
JUDITH T. TERRY
TOWN CLERK (5}16)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1074-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
'New Existing X
Name Of Owner JACOBI, HENRY R., SR.
Mailing Address 1 JACOBI, CAROL A.
Mailing Address 2 BOX 165
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 7980 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 59.00 block 9 lot 3.000
Cross Street KENNEY'S ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �c��FFUCrCQ=
Town of Southold �� FLG` Application No. /d 7�
Judith T. Terry,
Town Clerk
• Town Hall, 53095 Main Road Yom. ••4;;;;.(:-
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� Residential I/
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p. O. Box 1179 Non-Residential
Southold, New York 11971 're�`
Telephone
(516) 765-1801
' TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
F€ 4199 •
OPERATION PERMIT
-
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 0,3k7-6" /99
•
OWNER NAME: //c91/�? eL/v.'d/ -/ r/1�C0/3,reie
OWNER MAILING ADDRESS: ,4 /6s—
.s0u..y 1.d /v y «9?/
OWNER PROPERTY ADDRESS: ?f.(f ) £, i rte , /Y
�SLVej A /r,?/
OWNER TELEPHONE NUMBER: 1. I/4- . 72-0
TAX MAP NO. : Section / Block Lot
CROSS STREET: /14--•"57-74---5r
p
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ' {/ New Existing ✓`
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: �`�i've-
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.)
igna r of Applicant
RECEIVED BY: 1,, 10�
Lierk's Office
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