HomeMy WebLinkAboutFerguson � Town Hall, 53095 Main Road
&"• _ P.O. Box 1179
=_ ® �I1�;i� Southold, New York 11971
gt.JUDITH T.TERRY i/ r- FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1136-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FERGUSON, MARY F.
Mailing Address 1 670 HICKORY ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 670 HICKORY ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1037
Tax Map No. section 54.00 block 6 lot 7.000
Cross Street SOUNDVIEW AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/08/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 5\\Tfp(f.�•
Town of Southold �� Q Application No.//3'
Judith T. Terry, Town ClerkE `
Town Hall, 53095 Main Road tsc, "`"" '< } Residential
P. O. Box 1179 cn . z Non-Residential
Southold, New York 11971 ����`�
Telephone �( Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /o,oe
DATE Cr 0
OWNER NAME: r7agy f; rZ Usd
OWNER MAILING ADDRESS: '� 7 /I/ 160 6s,
.3'0_0--7--) / N // P/
OWNER PROPERTY ADDRESS: — �i9-/7 �_ _-.�__-•wA
OWNER TELEPHONE NUMBER: (5-10$7 7Cd - /O3,
• TAX MAP NO. : Section � Block 6 Lot 7
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.)
JJ
Sig ture of pplicant
RECEIVED BY: 4- dce- _i ��aass�
b ,:e 5 n Clerk's 10ffice
DATE: SUN M°3'
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