HomeMy WebLinkAboutFisher (3) 1
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Town Hall, 53095 Main Road
- ® N.• P.O. Box 1179
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Southold, New York 11971
JUDITH T.TERRY 00/, 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. 1515-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FISHER, THOMAS AND CLAIRE
Mailing Address 1 680 BUNGALOW LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 680 BUNGALOW LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4101
Tax Map No. section 123.00 block 2 lot 9.000
Cross Street MARRATOOKA ROAD
Date Of Last Pump Out 0/00/62
Issue Date: 8/09/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ��F�
C'�
Town of Southold A lication No.
Judith T. Terry, Town Clerk pp
Town Hall, 53095 Main Road 7 $10.00 - Residential
P. O. Box 1179 cn :r '= *i �� $25.00 - Non-Residential
Southold, New York 11971 O
Telephone ''�
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee- $ /at
DATE d
'OWNER NAME: '--77,4 iq S c-s„L C,' //.Z. //e
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OWNER MAILING ADDRESS: 6efO 1J,0 I64 Lo& /4-'2/Z-
111977/7-vC.-4 ,4/, ) / //9SZ
OWNER PROPERTY ADDRESS: 54t /�
OWNER TELEPHONE NUMBER: .5/6 ' q/OJ
TAX MAP NO. : Section /,P,3 Block 2- Lot
CROSS STREET: ,tikP,eft/a wi 9'
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /9 4 ,2
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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Sig'=ture if Ap. leant -
RECEIVED BY: ,
6, 1.,,, Clerk's Office
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DATE: 'AUG Oa 19'3U -
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