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HomeMy WebLinkAboutGill Ie�oguFFOUrCo JUDITH T.TERRY �t ?'� Town Hall, 53095 Main Road TOWN CLERK ; y Z P.O. Box 1179 Southold,New York 11971 REGISTRAR OF VITAL STATISTICS may � '��� Fax(516) 765-1823 RECORDS MANAGEMENT OFFICER MARRIAGE OFFICER =� ao��i� Telephone(516) 765-1800 o 1 FREEDOM OF INFORMATION OFFICER �� OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3505-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner GILL, MICHAEL E. Mailing Address 1 BUTTERWORTH, BARBARA Mailing Address 2 P. O. BOX 60057 City St Zip PALO ALTO CA 94306-0000 Property Address 1 1875 JACKSON STREET Property Address 2 City St Zip NEW SUFFOLK NY 11956-0000 Owner Telephone No. 415-329-8428 Tax Map No. section 117.00 block 9 lot 14.000 Cross Street FOURTH STREET Issue Date: 8/22/96 Judith T. Terry Southold Town Clerk (TOWN SEAL) • I I OFFICE OF THE TOWN CLERK cSFQU ���� Town of Southold �� CDG Application No. Judith T. Terry, Town Clerk Town Hall, 53095 Main Road $10.00 - Residential v P. O. Box 1179 v' ► i $25.00 - Non-Residential Southold, New York 11971 ® %� ��`� Telephone _ 1 (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ '1 DATE 811 fr OWNER NAME: AA 1 C44 t- , A1-1- 1 0./-}L4wP1 �K 7'f AP 7"1( OWNER MAILING ADDRESS: e a• Q)( 6005-7_ 9z./34 . pm--0 ec vL`✓(pr- 6 a os OWNER PROPERTY ADDRESS : Le-i-1 F�C-��2)�'`� �✓ Svt�- o L� / i/( I I s OWNER TELEPHONE NUMBER: &IS 1 �4� TAX MAP NO. : Section 11 �- Block et Lot CROSS STREET: 9' B` 0A-C "" ei'\I STs . (Nv0 R4'10-1,2) TYPE OF SYSTEM:_.,Septic Tank _, New Existing Cesspool New Existing Residential Non-Residential 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.) Signatu Applicant RECEIVED BY: ' Town Cleric's Office DATE: - 1 k ett-t , .f_, ftciA -9. V 1 T el, I . > NI k P- 6 - - - - V ... di,t,<,,,c,0441) . 701 . AI - - - 5vrik - - 1© 0 " - j - - -