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HomeMy WebLinkAboutKetcham lie 0 III' JUDITH T. TERRY Town Hail, 53095 Main Road TOWN CLERK T P.O. BOX 1179 REGISTRAR OF VITAL STATISTICS R �. � Southold, New York 11971 MARRIAGE OFFICER � Fax (516) 765-1823 oie 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. 1627-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner KETCHAM, ELEANOR S. Mailing Address 1 626 MAPLE STREET Mailing Address 2 City St Zip GREENPORT NY 11944-0000 Property Address 1 626 MAPLE STREET Property Address 2 City St Zip GREENPORT NY 11944-0000 Owner Telephone No. 516-477-0946 Tax Map No. section 42.00 block 1 lot 14.000 Cross Street SIXTH AVENUE • Date Of Last Pump Out 0/00/00 Issue Date: 2/20/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFF'YCE OF THE TOWN CLERK cOFO tow of Southold % eo ' Application No. /G 2. 7 Judith T. Terry, Town Clerk • rkµ a t a�f .0 $10.00 - Residential ✓ Town Hall, 53095 Main Road ° P. O. Box 1179 v' ? ^ i %� $25.00 - Non-Residential Southold, New York 11971 "feikr4;'--$% ' 0 �Telephone ' (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ DATE 1. , I OWNER NAME:• OWNER MAILING ADDRESS: 7,7 Ark-/-A4DAA-i , Le Lk OWNER PROPERTY ADDRESS : to aY1'1-0,�i2z._ L OWNER TELEPHONE NUMBER: Lit ) . © Cl L TAX MAP NO. : Section 2- Block 0 Lot -i` `- CROSS STREET: TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: 11141.)- . cX 0 1 I cj cl o LOCATION MAP: Must be attached hereto before permit may be issued. av• (Locate building and system; give north arrow and feet of distance, approximately. to building and closest road.) oinz r! Signature of Applicant RECEIVED BY: Town Clerk's Office DATE: 11.21/4•61r/ [ (li:'f a a g FEB2 6 1= • ov-c".4'4,4 c_t#6 kk ‘r\ ove4-0.1 p•• .,_ 4A,L.Lwa.t. _ I as14,0k "T- t-0 S =