HomeMy WebLinkAboutJackson (3) JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ° �� Fax 516 765-1823
MARRIAGE OFFICER _ '�� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 121-N Residential Non-Residential X
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner JACKSON, JESSE
Mailing Address 1 P. O. BOX 2066
Mailing Address 2
City St Zip AQUEBOGUE NY 11931-0000
Property Address 1 MAIN ROAD
Property Address 2 BAYSIDE DELI
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-722-3148
Tax Map No. section 61 .00 block 2 lot 8.000
Cross Street YOUNGS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/27/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
4� , ` III AZ/
OFF1dE OF THE TOWN CLERK COFair"' .
Town of Southold 0�% >, V Application No. _-
Judith T. Terry, Town Clerk % .:
Town Hall, 53095 Main Road = ' 0.4 1 $10.00 - Residential
P. O. Box 1179 cn '0,,,i;:-?:.;L �`'
$25.00 - Non-Residential
Southold, New York 11971" v. ®_ �`�
Telephone Ql ��� ''•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 50 l )v
Fee $ 2. 0 p
l'
' DATE 6�,.43S i 2 z� /?9/
OWNER NAME: z Aa IC Sc. ®1.sS 6a-re--,A-e- /Q /
OWNER MAILING ADDRESS: p..0. . B S( 2-6 ea b
i\ 4 u-cr3OGUe )v`/ llf z_______
OWNER PROPERTY" E.1 ADRESS: _�_
, - �, . f
. ,, , 3 f nil( N `
f() p
- . c Sou17-1aLp /0-'27
OWNER TELEPHONE NUMBER: 12.2-� 3 j 4-(
TAX MAP NO. : Section l0 i Block 2, Lot 000
CROSS STREET: E9 N &-S AVEhl(-5r-
TYPE
OF SYSTEM: Septic Tank (7 New i! Existing
Cesspool I/ New ,V Existing
Residential Non-Residential V
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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dh;/
of Applicant
RECEIVED BY: LUQ"--4
, )1.
own Clerk's Office
DATE: b �/
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