HomeMy WebLinkAboutFaller JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK : P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 5=2 rTit
tr5
`�'' Southold, New York 11971
MARRIAGE OFFICER ® �1 Fax (516) 765-1823
--�® � �� Telephone (516) 765-1801
_. 101
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1728-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FALLER, JOSEPH M.
Mailing Address 1 P. O. BOX 596
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 405 OAK ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6445
Tax Map No. section 110.00 block 8 lot 12.000
Cross Street NEW SUFFOLK ROAD
Date Of Last Pump Out 0/00/74
Issue Date: 7/26/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK c0FOCr
CQ
Town of Southold �� ' Application No. /72f
Judith T. Terry, Town Clerk " $ %}
Town Hall, 53095 Main Road ~'=': $10.00 - Residential
P. O. Box 1179 (fl ' z $25.00 - Non-Residential
Southold, New York 11971 'roe*
Telephone Telephone = .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for •
OPERATION PERMIT •
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 .
I �
DATE AliaigidoZ /F
OWNER NAME: cD //'/41 tri /%-/ R
OWNER MAILING ADDRESS: p,,,O • SSC 5-TZ
C U %C aG UL /i ( S
OWNER PROPERTY ADDRESS: (6o Cy ,*/r /�l>
OWNER TELEPHONE NUMBER: 7 5 `4 - Ca
TAX MAP NO. : Section / //) Block Lotf
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ) New Existing
Residential )° Non-Residential
DATE OF PREVIOUS PUMP-OUT: /f
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.)
S•gnature of Applicant
RECEIVED BY:
J
-E�°�'���Tow Clerk's Office
DATE: 1991
JUL 2g lac ' •
Ion
��,; Cie " •`t