HomeMy WebLinkAboutJahn JUDITH T. TERRY `� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS t, rri
' Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
® ,'• Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1784-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JAHN, ALFRED H.
Mailing Address 1 3925 NORTH ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 3925 NORTH ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1224
Tax Map No. section 35.00 block 2 lot 5.000
Cross Street WIGGINS LANE
Date Of Last Pump Out 10/00/84
Issue Date: 10/09/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.21
"OFFICE OF THE TOWN CLERK c.3VFFOur
��=
C A lication' No.
Town of Southold - �� -•: OG__; pp /7�y
Judith T. Terry, Town Clerk :
Town Hall, 53095 Main Road
}, $10.00 - Residential ✓
P. O. Box 1179 cr3 i= `; i ;' $25.00 - Non-Residential
Southold, New York 11971 OXY �0���
Telephone 1 %
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
-for
OPERATION PERMIT
•
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 06A/
OWNER NAME: ///),1-45i /LA
' ';• �j'. `"
OWNER MAILING ADDRESS: ...19.1f— /1i ?/ / 7,70/4-13
6-fre.427Z3re/e/-Ajlif 4.1,54
OWNER PROPERTY ADDRESS: Ly.
OWNER TELEPHONE NUMBER: *- 1-17 4 . • - -
TAX MAP NO. : Section 3S—
Block '' Lot
glliaSS STREET: A✓/ 6-6=/)7s
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool )C New Existing X
- Residential Non-Residential
DATE,OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and1 feet'
of distance, approximately, to building and closestroad.)
,/gnature . Applicant
•
RECEIVED BY:
REC1G� Clerk's Office
DATE:
tom CIO Southold
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