Loading...
HomeMy WebLinkAboutMcburnie eor ���gyp`• CIO JUDITH T.TERRY t _ • Town Hall, 53095 Main Road TOWN CLERK ; y P.O. Box 1179 v. r �� Southold,New York 11971 REGISTRAR OF VITAL STATISTICS ® .1 Fax(516)765-1823 MARRIAGE OFFICER �� ®v��0 RECORDS MANAGEMENT OFFICER : .( -1%.„0 Telephone(516) 765-1800 FREEDOM OF INFORMATION OFFICER �� OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3431-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner MCBURNIE, JAMES/JOZEFA Mailing Address 1 41780 ROUTE 25 Mailing Address 2 City St Zip PECONIC NY 11958-0000 Property Address 1 41780 ROUTE 25 Property Address 2 City St Zip PECONIC NY 11958-0000 Owner Telephone No. 516-734-6350 Tax Map No. section 86.00 block 1 lot 7.000 Cross Street INDIAN NECK LANE Issue Date: 2/02/96 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK ���FF� Ur"'Town of Southold &.,v� c ( �j Q Application No. Judith T. Terry, Town Clerk Town Hall, 53095 Main Road -< $10.00 - Residential z/ P. O. Box 1179 . cn - �` $25.00 - Non-Residential Southold, New York 11971 O 0*-$ Telephone 0.( * y►� '0 99 (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION - for _---- - OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ Jo, 07) DATE / "('(° • OWNER NAME: �js S2 ---f./.9 / '/C,gU4-.0%t OWNER MAILING ADDR SS: o2 / . ( �i� OWNER PROPERTY ADDRESS: \S-1/ OWNER TELEPHONE NUMBER: dy TAX MAP NO. : Section 4/75ST? Block j Lot — 1 —7 CROSS STREET: Ii TYPE OF SYSTEM: Septic Tank New Existing Cesspool �,- New Existing Residential ,/Non-Residential 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.) • i Signature of Applicant RECEIVED BY: _..._ Town Clerk's Office DATE: ' " � > , • ,, -.._. .-- -- -._-_.. .... __-,••• t ,.. ... .. 10 , - ., . . • - _ .-..• " - . --. • : ' ,TOWN OF SOUTHOLD , , ,,,,, ,• ,,,,,,,,,,,..... ... % co-- , ..., . it.,= . _ , ' r<% -, ,,Ticket No. 1211'4. ;,,.,- ';;`,':'', '-,:•,-,''e ,':. AR: . - SCAVENGER WAS .E" `E P 0 R T :"-----P * 0-?".. - ----„„,,,• . . Name of Hauler • '' ' to,1 - .'`..,,L. ,....L.5.. Full Load44., ,A,4call • . • PerMit No.,:- :-; •:`; ..:,-- .", 0 Half Load @ Gallons ,-..-•••-•:,.;', ,..:;,, ,- . , , - Truck Capacity :' - - ''•A :':Cigf,„„,:•'47;47,„1-01, 0 $ Paid ' .N,-. .,- -•,;•.-;?1-40,--.4' . (date) , • LOCATION:',, :-.-:;` .'':,,0:,'5pIit load @ Gallons i - -•.-. .- • --,- - - • • _ " - (Validation of Payment) ' • -,-' - ,0 New- '' • ' 'Er Reiieat _• d „ e 0 , , r, ', Name of Ovin,er- ' - r; 00511" ,..t.h.....q..... Street - .e 6 ' , ., i . Hamlet ' —-- Telephone No. aig..45....".. 5, (:).i.... Tax Map No. ff. -‘-' ./— 7 , Cross Street.....• •"'"-- -I% e- --.- , DIAGRAM (Locale boildIng§and cesspool/septic system and approximate distance in feet Ir . . -.- -..- s•';,'— betWeeri-,birilairigs•and • , '- , --,'. /./e-ee/r....."--, .' Af i . , ,,i, ' ,; ';,",,, ;,'''.'; ' : ?„,,i'' k'' '' ,',''.•,f",','"f-,,T?:,, ' , , . , .- - - , • I , , .. ''s- ,.'"'-':* , ;' ,''" -''''.;:-:' • ' ,'. • , I hereby certify kliaithe,:.96OV6:or,ijiriafed within the Town.of Southold/Town of Shelter Island -• •-- .at the above location, arid464hei beataf my knowledge contains no chemicals, hazardous, or - , ` , toxic.wasteS:- False'state,Me`nts qiade,herein are punishable as a misdemeanor pursuant to' • , , Section 210-45 of the Penal•KciV"Of the State of New York, and May result in my arrest and the impoundment of itie Vehic1- a .' 'riving.'' OA ,46 . , Awed. , , •,-,-, - -Name of Driver • -, Or , ,. Signature of Driver c ' i i , . • • . , .•, , ,.. 4r, , 1` r)- I4i.,,,$).r,. .,,,, ,-,_,,, ' , Time - 40), , .' -,• ,,. : ,i- • •,),.t. ' ', ': '',:''' • ' '-,i-::-.'''; ',-;-',.•;, ,'-,:',.- - '!., • .fl • ,.. .,,.. ‘. • - ,,,,,,,- ••- --_, (1)Treatment Plant __,LL._-______:.•11:,.._-_______:..__.:__L_:.1. _:_________________ _ _ .--