HomeMy WebLinkAboutPollack JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ®
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER ® �" r
A, ` 14.-0 Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2090-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner POLLACK, GRACE FALLON
Mailing Address 1 EVA COURT/8TH FLOOR
Mailing Address 2 36 MACDONNELL ROAD
City St Zip HONG KONG 00000-0000
Property Address 1 150 TERRY LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 852-530-1357
Tax Map No. section 65.00 block 1 lot 4.000
Cross Street TOWN HARBOR ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FOLA' =
Town of Southold CQ� Application No. 02() DJudith T. Terry, Town Clerk ' �''l
Town Hall, 53095 Main Road
Wiz C'.. - .•C, $10.00 - Residential ✓
c
P. O. Box 1179 LT-30;z- �= � ;
$25.00 - 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 $ '11101®�
DATE 44,
OWNER NAME: G1 Q- cekkto0 20kck
OWNER MAILING ADDRESS: i�/� C.*3tJf I I cli"00i2%
3 (� nre-U0 2-4. I$o n 9 kork3
OWNER PROPERTY ADDRESS: ks--0
OWNER TELEPHONE NUMBER: (�sa) 530 -13 C7
TAX MAP NO. : Section \(f i) Block Lot !� /
CROSS STREET: 1OLji' 4 R-�04
TYPE OF SYSTEM: Septic •Tank ' New Existing /
• Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,Q, Slb 192N
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.)
Signature of Applicant
RECEIVED BY: •
Town Clerk's Office
DATE: