HomeMy WebLinkAboutJacques lele5VULA (of-
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r ; �` r, Town Hall, 53095 Main Road
A�'' `�. P.O. Box 1179
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� Southold, New York 11971
JUDITH T.TERRY � II��'� TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR Oh VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 934-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JACQUES, PETER
Mailing Address 1 11655 MAIN BAYVIEW ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 19971-0000
Property Address 1 11655 MAIN BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1033
Tax Map No. section 88.00 block 1 lot 8.000
Cross Street LONGVIEW LANE
Date Of Last Pump Out 0/00/00
Issue Date: 11/29/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
R 1,
OFFICE OF THE TOWN CLERK c�FFO(�
Town of Southold � CQG' Application No. 93V
Judith T. Terry, Town Clerk �,4 ;,z':
.-
Town Hall 53095 Main Road � �� ;� - Residential
P. O. Box 1179 ® �` Non-Residential
Southold, New York 11971 ®
Telephone ot ill 1% to
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE //-a7- S5`
OWNER NAME: PETER o_6 (/E ,�
OWNER MAILING ADDRESS: /7656-- /214/4/ ivg ;i
S eoT 6LD, ALT // VA)
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER: 3/765-----10 3 3
TAX MAP NO. : Section � r Block / Lot r
CROSS STREET: .Z VA/6-P/1L''i/ 4.A-11/
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential a/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: L �
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.)
ignat AAp cant
RECEIVED BY: c
Town CI k's Offi e
MEM
DATE: •
Town Cada S®utri���
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