HomeMy WebLinkAboutJacobs (2) OFFICE OF THE TOWN CLERK 6 OF-VS(
Town of Southold � dy
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Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - A a
P. O. Box 1179 V cn -. R �=
Southold, New York 11971 ` ,Q ..
Telephone4jt )�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 269 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Henry B. and Anna Jacobs
OWNER MAILING ADDRESS: Second and Main Street
New Suffolk. New YOrk 11956
OWNER PROPERTY ADDRESS: Second andMainStreet
New Suffolk. New York 11956
OWNER TELEPHONE NUMBER: 516-734-6548
TAX MAP NO. : Section 117 Block g Lot 73
CROSS STREET: Corner of Second and Main Street
TYPE OF SYSTEM: Septic Tank New Existing;
Cesspool X New Existing? X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: December 3,1986
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Judith T. Terri
Southold Town Clerk
DATE: April 13, 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3V9J -
Town of Southold ��o ^Q! Application No. (776,
Judith T. Terry, Town Clerk , '}
• Town Hall, 53095 Main Road aw ;7:V :47=
7 Residential
P. O. Box 1179 u7 '4 �• ;' Non-Residential
Southold, New York 11971 O ® '� $
Telephone .( 4-01;�
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /c ab
DATE . e30, l�y7_
OWNER NAME: ;11e/x1 2d Lot `
OWNER MAILING ADDRESS:, /`
L � iw54j 7.//Q-S'�
OWNER PROPERTY ADDRESS: , , —�
7? 1 t 7/y. /119-C-6
OWNER TELEPHONE NUMBER: ,5/ ���G_ 1,,
TAX MAP NO. : Section fr//3/ Block//_ 91.,z3 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 4-- Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,a,„,_„,_,4„ 4 /Frt.
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 atur f Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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