HomeMy WebLinkAboutMacomber (2) "ist, wit
Town Hall, 53095 Main Road
�` ��'. P.O. Box 1179
_®/�„9 v*O.
��! Southold, New York 11971
``_'' s2 TELEPHONEJUDITH T.TERRY ® ° TEL 765-1801ONE
TOWN CLERK (516)
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. 925-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MACOMBER, WILLIAM AND JUDITH
Mailing Address 1 4040 DEEP HOLE DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4040 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5916
Tax Map No. section 115.00 block 17 lot 4.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 11/21/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold grAY
� UC '�](�.CQ ' Application No. (
Judith T. Terry, Town Clerk . i .. .0
Town Hall, 53095 Main Road � �` Residential
P. O. Box 1179 Non-Residential
Southold, New York 11971 OO �0 ��`�
Telephone .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATEg-U , ai1 19 Fr
OWNER NAME: /a (,/jlyl (
yo ito n '
OWNER MAILING ADDRESS: C 'G�- Lt
OWNER PROPERTY ADDRESS: £/o Za ,1 'p /( oLe 2r,
u plc
OWNER TELEPHONE NUMBER: o2.9O9—._S-91
TAX MAP NO. : Section //5— Block / Lot V
CROSS STREET: , %
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 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.)
_ca A/ Z(//lal4
Signature of . p• icant
RECEIVED BY: (JLc. •
Town Clerk's Office
DATE:
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