HomeMy WebLinkAboutLueckoff JUDITH T. TERRY %��f y� Town Hall, 53095 Main Road
TOWN CLERK ae P.O. Box 1179
REGISTRAR OF VITAL STATISTICS i Southold, New York 11971
MARRIAGE OFFICER ` 1 Fax (516) 765-1823
�� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1677-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LUECKOFF, VERNON AND WIFE
Mailing Address 1 P. O. BOX 211
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 SPRING LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-734-7559
Tax Map No. section 86.00 block 5 lot 6.000
Cross Street INDIAN NECK LANE
Date Of Last Pump Out 0/00/79
Issue Date: 4/29/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •�U��O(�. =
Town of Southold 0�% ��-- 4-e/ - Application No. /6 7
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road �.�-. -' $10.00 - Residential
P. O. Box 1179 ' $25.00 - Non-Residential
Southold, New York 11971 �0 eTelephone : i
414-
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 471,2- 2 j'J
OWNER NAME: LU �C ®�� � �Nd DLJ WR_ • •
OWNER MAILING ADDRESS: C) )90--) I�
OWNER PROPERTY ADDRESS: PQ f3Ox' cII� �g./' 6' - c
P c ii c iv -y • 1 jqcg
OWNER TELEPHONE NUMBER: `7 -- `7 s--s--9
TAX MAP NO. : Sectionf' Block Lot
CROSS STREET: / k /,4-14 1\G z K-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,?
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.)
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Signa ':re d App icant
RECEIVED BY:
Town Clerk's Office
DATE:
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