HomeMy WebLinkAboutGildersleeve (2) yam" Town Hall, 53095 Main Road
V' P.O. Box 1179
s
/ Southold, New York 11971
JUDITH T.TERRY ii�' TELEPHONE
TOWN CLERK (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. 885-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GILDERSLEEVE, JAMES
Mailing Address 1 PIKE STREET
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 PIKE STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8409
Tax Map No. section 140.00 block 2 lot 22.000
Cross Street WICKHAM AVENUE/LOVE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/14/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
Of Ow.
OFFICE#OF THE TOWN CLERK ��
Town of Southold � C'2 Application No.
Judith T. Terry, Town Clerk .` Y4�,�, -
Residential
Town Hall, 53095 Main Road
.
P. O. Box 1179 _ ; ._•.; Non-Residential
Southold, New York 11971 O=�r k•, `-
Telephone lr
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
• 1
DATE ,illor
I / 8P
OWNER NAME: 1g a.5
OWNER MAILING ADDRESS: - 5 l
P7 7-77 -7-7 (` s
OWNER PROPERTY ADDRESS: ri` '
OWNER TELEPHONE NUMBER: 5/b .2913 - 8 ,91, fi
TAX MAP NO. : Section / q() Block Lot
CROSS STREET: 9 ( kg,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: --N.,„\71-
LOCATION
-N.,nLOCATION 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.)
•
'itignature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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