HomeMy WebLinkAboutJeavons $ Town Hall, 53095 Main Road
® �r P.O. Box 1179
__ ®1 sla' � oo' Southold, New York 11971
JUDITH T.TERRY „„„
---- o' TELEPHONE
TOWN CLERK (516)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. 716-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner JEAVONS, GERTRUDE
Mailing Address 1 BAYER ROAD
Mailing Address 2 BOX 1122
City St Zip MATTITUCK NY 11952-0000
Property Address 1 BAYER ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8467
Tax Map No. section 139. 00 block 3 lot 12. 000
Cross Street WICKHAM AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/27/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK SFF U( -
Town of Southold � - CQG' Application No. 776
Judith T. Terry, Town Clerk ►,
Town Hall, 53095 Main Road "`'le Residential
P. O. Box 1179 Z' Non-Residential
Southold, New York 11971 �y�� rT�O�'���'
Telephone ,(
(516) ,765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
'Fee $ o 1
DATE111 /0-7 (72-3 ( �0'
OWNER NAME: G rt_.7MCI
OWNER MAILING ADDRESS: ej fr f LJ VI- (-0 lo-p Ac
G ft 4 11 t 1 v ,- f Ley,s' 'v
OWNER PROPERTY ADDRESS: 51 /)-
OWNER
OWNER TELEPHONE NUMBER: cd O 67 -
y TAX MAP NO. : Section /3 Block 3 Lot
CROSS STREET: tt/L li , et 4h C
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool ok New , Existing £ 5)6e
Residential ( S Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1'- `3 /5 4 -1 m
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.)
-1Zl21,(.id-,9 C.
Signature , f Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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