HomeMy WebLinkAboutJacobs OFFICE OF THE TOWN CLERK • •c51FOUrtx.
Town of Southold
Judith T. Terry, Town Clerk � ,� ,�
Town HaIl- 53095 Main Roaditt W17:41,44
P. 0. Box 1179 cr3 Na t
Southold, New York 11971 O ® .1" Nr •
Telephone ®( str
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 487 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Douglas and Jean Jacobs
OWNER MAILING ADDRESS: Old Wood Path
- Southold. New York 11971
OWNER PROPERTY ADDRESS: Old Wood Path
Southold. New York
OWNER TELEPHONE NUMBER: 516-765-2701
TAX MAP NO. : Section 87 Block 1 Lot
CROSS STREET: South Harbor Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Never previously pumped. •
Judith T. T ry
Southold Town Clerk
DATE: November 20, 1987 I I
•- i
(TOWN, SEAL)''
•
// ".•
OFFICE OF THE TOWN CLERK : sS�FFair
Town of Southold �O CO ',, Application No.41 7
Judith T. Terry, Town Clerk .
Town Hall, 53095 Main Road VA' '' Residential
P. O. Box 1179 v' rog Mg; Non7Residential
Southold, New York 11971 O ®_, .- istvi
'• Tlephone :®(
•
(516) .765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL- DISTRICT
APPLICATION
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. "Te--)
Fee $ /6.60
DATE
OWNER NAME: loug /4.S t=A4 V 4106
OWNER MAILING ADDRESS: ane ci ?
S0 tfr4 0 id
7
-._- OWNER _PROPERTY ADDRESS: _-_ _SA e y,_t__
OWNER TELEPHONE NUMBER: 57 " '7(.3�' 2760
- t
TAX MAP NO. : Section g i Block [ Lot -
CROSS STREET: ! �, Ve210.4,6t.{rt
c
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: l6., _, 44�,� a•
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.)
X082,,L4,A1P
S. nature/.f Applicant
RECEIVED BY:
riss , ,L
oW-nirerk'es(ffice
reEIVED
DATE:
PM(20 1987
Southold Town Clerk,
`I ,
)
cAtt
-2_.