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HomeMy WebLinkAboutJersey '21Z t ® 77i u; Town Hall, 53095 Main Road CO P.O. Box 1179 �e„i,� Southold, New York 11971 JUDITH T.TERRY = 1IFAX(516)765-1823 ����, TELEPHONE(516)765-1801 TOWN CLERK 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. 1315-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner JERSEY, RICHARD AND HILARY Mailing Address 1 8415 SKUNK LANE Mailing Address 2 City St Zip CUTCHOGUE NY 11935-0000 Property Address 1 8415 SKUNK LANE Property Address 2 City St Zip CUTCHOGUE NY 11935-0000 Owner Telephone No. 516-734-5819 Tax Map No. section 104.00 block 3 lot 11 .000 Cross Street PINE TREE ROAD Date Of Last Pump Out 0/00/00 Issue Date: 11/21/89 Judith T. Terry Southold Town Clerk (TOWN SEAL) 0 • III OFEIC[ OF THE TOWN CLERK : c3\\V.FO(,' town of Southold �® --;',01.. CQG- Application No. 13 I Judith T. Terry, Town Clerk ' : y:•i Town Hall, 53095 Main Road "' .4 ::" $10.00 - Residential ,� P. O. Box 1179 cr) ' t '-` ., i • $25.00 - Non-Residential Southold, New York 11971 O �,,"- " . -0 es Telephone ,� `A (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL - Operation Permit No. Fee $(0 , ' DATE j ( , - ( - 7 _ . OWNER NAME: Jf f/,LRL/ JERSL- ' OWNER MAILING ADDRESS: g ( ( U/fj< L .41-/I/,8- CUT e.I# oGoC 1 iVY //?i.s" - OWNER PROPERTY ADDRESS: sr/ 05- -.,3 /< tl f/ k' L A7i/g C u-,-ci OG uE, /V/ / // 9. ,s OWNER TELEPHONE NUMBER: Com'/ (,) 73 ' - .5 8 / 9 TAX MAP NO. : Section /py Block 3 Lot /f CROSS STREET: Er ` LIFE' 0 TYPE OF SYSTEM: Septic Tank New Existing Cesspool V- New Existing Residential V Non-Residential DATE OF PREVIOUS PUMP-OUT: /0 /g7 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.) //fl___________ _______ ,, A._ / ._ .__— -41.1sor- ._,,.." ;764,4- ,,,,,, Signature of A4pp a'nf ____------- c....(_:;:z RECEIVED BY: il„. l,, own Clerk's fice DATE: l( / g7 P,S1,-.K3,:trl',4-1,Wig-c-s"4134'-'31-:137,T-1-'-q,;.-,,"',,--.-',,!- 1-",,"4-1-3-..k"43,.•'.?--4,?-;-'"--;*,:----',? 3,--.. /„,. - . , ''.;3,,' •, •, -,..-:•,,„,,''''..,,f,,,,,-1--;•,,,;-.....,,''',f 5 ', 0 •:'"' '7 ' 4;4'4: 44+.4j,12',''-'65- ,•0"; •-•°4• -,g.'.- • '',-.'45'4'0'• ,., 4, • °''•0,;• ,4 • '.?'' •4'•.L',' , ,. , . . °4 ,. . *,,,,.. .,. :,:,-,,,,,,, ,,. ,,,,.,,, ,.•, ... , „,. ', - '.., . ' . _, IV I _ A,.- . , -., / . , 6„--. : , ....., . ,./4 • , „ . '' e t 4 1 .... ,, • . 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