HomeMy WebLinkAboutFleischman JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK p T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER yQ ®�' ��, Fax (516) 765-1823
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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. 3027-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FLEISCHMAN, MARY ANN
Mailing Address 1 P. O. BOX 1664
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1385 PIKE STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8764
Tax Map No. section 140.00 block 2 lot 40.000
Cross Street WICKHAM AVENUE
Date Of Last Pump Out 4/20/93
Issue Date: 5/18/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.•1' Y4,y
OFFICE OF THE TOWN CLERK
Town of Southold 0c3 �FO et. Application No. 0.2,7
Judith T. Terry, Town ClerkK x1 $10.00 - Residential ✓
Town Hall, 53095 Main Road
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971O ® ' `0-1$16 Telephone �j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ � - in
DATE _/5---c/3
OWNER NAME: ThIY g 4iti ' Pi-ETC CIO ,
OWNER MAILING ADDRESS: f-D- teD /a U/ l
0-Tr Tuck, nay lfif 5 5--a--
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OWNER -PROPERTY ADDRESS /3 g 5 4y -f i< S`0
f)- r7 /TV ci<
OWNER TELEPHONE NUMBER: 57 o aq ' 87eact
TAX MAP NO. : Section 1 to, 00 Block (a,°00' Lot 00, O O
CROSS STREET:- .-..
TYPE OF SYSTEM: --Septic'TankT- ° New Existing
Cesspool New Existing ✓
Residential Non-Residential
DATE OF PREVIOUS 'PUMP-OUT: ` gt9 -93
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.)
/
///'
gnat. <e of Applicant
RECEIVED BY
' .• `` ``' °" Town Clerk's Office
DATE:
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