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HomeMy WebLinkAboutLockman OL tel C:3 t9e, • rT' '` Town Hall, 53095 Main Road =ie ��, , , P.O. Box 1179 �� 0$ Southold, New York 11971 JUDITH T.TERRY ,r�i��. FAX(516)765-1823 TOWN CLERK TELEPHONE(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. 15611-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner LOCKMAN, ROBERT Mailing Address 1 P. O. BOX 2 Mailing Address 2 City St Zip LAUREL NY 11948-0000 Property Address 1 1420 LAURELWOOD DRIVE Property Address 2 City St Zip LAUREL NY 119118-0000 Owner Telephone No. 516-298-11383 Tax Map No. section 127.00 block 5 lot 6.000 Cross Street HEATHER PLACE Date Of Last Pump Out 0/00/00 Issue Date: 10/23/90 Judith T. Terry Southold Town Clerk (TOWN SEAL) •iti E • "- • OFFICE OF THE TOWN CLERK �C3\\V (K�'- '/ Town of Southold � - BOG- Application No. /�- `7` Judith T. Terry, Town Clerk % Z` '- .%'\ $10 .00 - Residential Town Hall, 53095 Main Road a -� , . P. O. Box 1179 L17 ,-i`: 'Z.'%� , ,� ,,�;. � $25.00 - Non-Residential Southold, New York 11971 O ®r `4-:F' F-tie��`� Telephone 61 0,. (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ (d DATE 101(5190 - - 'OWNER NAME: -Briber+ 1--mkyrc r OWNER MAILING ADDRESS: i'.O.B©)C 2 LLt,ut,re(1 N .y, l L L OWNER PROPERTY ADDRESS: 1420 Lau! ( woad v.e Lau,re() Nvy ACNS OWNER TELEPHONE NUMBER: aq-'..x.3$-3 TAX MAP NO. : Section 12.7 Block 5— Lot l.0 CROSS STREET: qch€,( .Q,Ce,> TYPE OF SYSTEM: Septic Tank New Existing • Cesspool New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: t-;CSHIrfle,. in ((a ltocr5 when i IlSittiViett 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.) 4reaPiet /4-04/4- Signature of Applicant RECEIVED BY: Town Clerk's Office , DATE: to • n U '� • 042 I T.9 _..,. — -••••1% 111 , , p' ' ci 4 .... "--2 , , 10 1 ,, E gt ..... -t.• _ . ,,„, 1 e � • N '9.4.idri otig . . . , .. , . . 7.. coq