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HomeMy WebLinkAboutJohnson (7) !8 t JUDITH T. TERRY t. Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICS en • Southold, New York 11971 MARRIAGE OFFICER 9,100 ��` Fax (516) 765-1823 s1' 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. 1787-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner JOHNSON, ROBERT E. Mailing Address 1 40-24 208TH STREET Mailing Address 2 City St Zip BAYSIDE NY 11361-0000 Property Address 1 430 KOKE DRIVE Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 718-224-1438 Tax Map No. section 87.00 block 5 lot 3.000 Cross Street MAIN BAYVIEW AVENUE Date Of Last Pump Out 0/00/80 Issue Date: 10/10/91 Judet err Southold Town Clerk (TOWN SEAL) • '% I, IS.�'I OFFICE OF THE TOWN CLERK c�vFFO(,- Town of Southold �� CQ ' Application No. I'7 EC-7 Judith T. Terry, Town Clerk ir' x s 53095 Main Road Town Hall, -'� $10.00 - Residential � ���� �„ �� '- P. 0. Box 1179 cn `� ' • $25.00 - Non-Residential Southold, New York 11971ho. '" ����''` Telephone .� I sr (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. /7 ?� Fee $ /1-a -- DATE OWNER NAME: ! ©(36/27- J69 /4Arg‘Szz) ,� OWNER MAILING ADDRESS: i � ' I6 OWNER PROPERTY ADDRESS: 41)&4-- �� s- OWNER TELEPHONE NUMBER:SUUf ��, _�iC�� >6:4-&-A 0/6 Z-z.-rG J,iGs " TAX MAP NO. : Section 3 Block 5 Lot 2 CROSS STREET: . 14 /A/ a�� Vk \i/ 4-- TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential C1 Non-Residential DATE OF PREVIOUS PUMP-OUT: r ( 9? 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.) p i7 /3- Y gnature of Ap icant RECEIVED BY:, 4 I Town Clerk's Office DATE: � - — - Sky WE vti Pkv-c- it3o '667-- 6( • [1/Vri EE r6( . /'igff—i dF tt)ky )(4)47-1-(- 1\ bb f1 a � loreer1(ISS% rep/4C/8--Y 1 °647. --12