HomeMy WebLinkAboutLake (2) ''� Town Hall, 53095 Main Road
w® '1 P.O. Box 1179
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Southold New York 11971
JUDITH T.TERRY Ill l�i� 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. 676-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner LAKE, JON T.
Mailing Address 1 P.O. BOX 135
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 GLENWOOD ROAD
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5435
Tax Map No. section 110. 00 block 6 lot 4. 000
Cross Street PEQUASH AVENUE
Date Of Last Pump Out 0/00/00
1
Issue Date: 4/28/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
r e
OFFICE OF THE TOWN CLERK � . FD 7
Town of Southold D%�_ a; 4.--- Application No.6
Judith T. Terry, Town Clerk ' :
Town Hall, 53095 Main Road i "'` : .4 } Residential
P. 0. Box 1179 i' ., 744,0 �% Non-Residential
Southold, New York 11971 O '.� to`,,.,, ' '
Telephone `��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE / /7/Ar2C
OWNER NAME: / e 1------ife---
OWNER MAILING A DRESS: "094/ / -
-
5
OWNER PROPERTY ADDRESS: c5 / ‹.--e___
OWNER TELEPHONE NUMBER: 731 — A/3
TAX MAP NO. : Section //61, CO Block 6 (r 0 a Lot 0*, ® P 6
CROSS STREET: -1 7-- ! .'. - : ;.- -�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential i" Non-Residential
DATE OF PREVIOUS PUMP-OUT: rr/'d��
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.)
Signature of Applicant
RECEIVED BY:4,--x.r;(,/c..
Town 1erk's Off`ce
RECEIVED
DATE: APR 2 S 1988
Town Clerk Southold
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