HomeMy WebLinkAboutMack JUDITH T.TERRY t ?`� Town Hall, 53095 Main Road
TOWN CLERK 2 P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ® ,
MARRIAGE OFFICER Fax(516) 765-1823
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• � Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER - I'.' .�����
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. 3723-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MACK, JOHN AND PHYLLIS
Mailing Address 1 P. O. BOX 1837
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 975 ANDERSON ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2820
Tax Map No. section 50.00 block 1 lot 15.000
Cross Street SOUND VIEW AVENUE
Issue Date: 11/13/97 - Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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or rod,
OFFICE OF THE TOWN CLERK �FFO
Town of Southold , �� CQG? Application No.37"2-5
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -� $10.00 - Residential
p. O. Box 1179 v' $25.00 - Non-Residential
Southold, New York 11971 O /�`
Telephone .(
41 siti
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: I
,9
OWNER MAILI 'ADDRESS: i I '
•C /IQ-7/
OWNER PROPERTY ADDRESS: 9 23 67,,frutez�. 1
aeeA9, h : /1,9 /
OWNER TELEPHONE NUMBER: 6 6 •---76,-C—
TAX MAP NO. : Section c.5-0 Block / Lot 7 S
CROSS STREET: ,Sf A.:),4 f9 / `�
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.)
////
0,7
bignature of Applicant
RECEIVED BY:
Town Cl rk's Office
DATE: RECEII +ED
N O V 1 3 1997
•
southold Tows Clerk
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