HomeMy WebLinkAboutGackenheimer JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® f P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ( .�` Southold, New York 11971
MARRIAGE OFFICER .'21t Fax (516) 765-1823
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Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1953-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GACKENHEIMER, LOUISE
Mailing Address 1 P. O. BOX 104
Mailing Address 2
City'St Zip MATTITUCK NY 11952-0000
Property Address 1 SIGSBEE ROAD
Property Address 2
City St Zip MATTITUCK - NY 11952-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 126.00 block 6 lot 7.000
Cross Street PECONIC BAY BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 8/04/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1
F4•CE •OF THE TOWN CLERK •c0FO(,i-�'
Town of Southold �� ... CQG Application No. /7-5-3
. Judith T. Terry, Town Clerk . 0%% 4,
Town Hall, 53095 Main Road w $10.00 - Residential
P. O. Box 1179 - $25.00 -,Non-Residential��`.
Southold, New York 11971 O `
Telephone( ��® '°°' •
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
rot-
OPERATION PERMIT
SEPTIC TANK or CESSPOOLS'
Operation Permit No.
Fee $ /0 , c o .
DATE
OWNER NAME: .op L's �� P1 � 2 ksyH,e�
OWNER MAILING ADDRESS: g•q,5co. Po 1307 ( 9l—
)1 Li ( ..s'
OWNER -PROPERTY ADDRESS: � ` 5 e_ . �o /b /?G
J te19 zL
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section / 2 Block 6 Lot !
CROSS STREET: -- _fa Z \3s._ '
c
TYPE OF SYSTEM:, Septic -Tank -, _ New Existing
3 Cesspools I New Existing 2 -
_ r
Residential ,/-- Non-Residential
DATE OF PREVIOUS PUMP-OUT: Da--, I�q� j S,��� (or j �.
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: o