HomeMy WebLinkAboutAlbertson e�,/ilii�-
�' $ htr. *� Town Hall, 53095 Main Road
- JUDITH T.TERRY � ,
TOWN CLERK s " P.O. Box 1179
rri Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(516) 765-1823
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MARRIAGE OFFICER �_*
RECORDS MANAGEMENT OFFICER ®� ��,���► Telephone (516) 765-1800
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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. 154-N Residential Non-Residential X
Fee $ 25.00 New Existing X
Name Of Owner ALBERTSON, ALBERT W.
Mailing Address 1 P. O. BOX 614
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 COLONIAL CORNERS
Property Address 2 MAIN ROAD
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-2830
Tax Map No. section 62.00 block 3 lot 22.001
Cross Street LOCUST AVENUE
Issue Date: 3/29/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ���VFU -
Town of Southold &,% 14% , Application No.e
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - $10.00 - Residential
P. O. Box 1179 to • • • M
$25.00 - Non-Residential
Southold, New York 11971 O ��`
Telephone ,(
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ j
DATE IY1a1-Cb (o
OWNER NAME: Ac&r4S01^ ) A I b 1?Jt W
OWNER MAILING ADDRESS: U 8 Ox (p t L(
o 1^014 ��, r ct i
OWNER PROPERTY ADDRESS: __C•OhM-k_c ' rnek-s
OWNER TELEPHONE NUMBER: 5+ (.0 - H 77 - Z5)
TAX MAP NO. : Section (09--3-Z2-Ii Block (1(")) Lot
CROSS STREET:. _ _
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.)
Signat -e of Applicant
RECEIVED BY:
_ Town..Clerk's--Office 4 �;: ;. .
DATE:
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