HomeMy WebLinkAboutFicner C74w ill Town Hall, 53095 Main Road
,' P.O. Box 1179
-\ Southold, New York 11971
JUDITH T.TERRY ,�d�` FAX(516)765-1823
�` TELEPHONE(516)765-1801
TOWN CLERK
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. 1324-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FICNER, FRANCIS S.
Mailing Address 1 685 VILLAGE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 685 VILLAGE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9410
Tax Map No. section 1 .14 block 6 lot 9
Cross Street MAIN ROAD
Date Of Last Pump Out 12/01/88
Issue Date: 11/30/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
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OFFICE OF THE TOWN CLERK �FFO(,r •
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Town of Southold �;; _ . y G Application No. j,9,2j,9,2Judith T. Terry, Town Clerk � , , Y • = �►` /
Town Hall, 53095 Main Road .ice � u : Residential
P. O. Box 1179 u7 ' � i ; Non-Residential
Southold, New York 11971 61..$312s
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1, :,3.9?//
Fee $
• DATE /7.- 30-8.9 C n
OWNER NAME: -Fe-m -s-, r,t C 5, R c,
OWNER MAILING ADDRESS: 6.4-5 { /��V' //a .'
, , / ) �¢
OWNER PROPERTY ADDRESS: Ser .ter ((��
OWNER TELEPHONE NUMBER: .5%1— >-7 — ,d-pa
TAX MAP NO. : Section / / 171 Block ,4 Lot
CROSS STREET: " .�: - Q � a a
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.)
11600411.
Signatur- of App icant
RECEIVED BY:
/1040
Tow ' Crrk's Office
DATE: /06)//7
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