HomeMy WebLinkAboutGillen OFFICE OF THE TOWN CLERK • coFOLk��
Town of Southoldlj
Judith T. Terry, Town Clerk a°T
Town Hall, 53095 Main Road 8 Pi, µ .
P. O. Box 1179 c13 �
Southold, New York 119714rd- '1111
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Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 350 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Paul_ H. Gillen Jr.
OWNER MAILING ADDRESS: Box 710
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: 12455 New Suffolk Avenue
Cutchogue, New York 11935
OWNER TELEPHONE NUMBER: 516-734-7442
TAX MAP NO. : Section 116 Block 2 Lot 6
CROSS STREET: Bay Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
•
Judith T. Terry
- Southold Town Clerk
DATE: July 15-, 1987 -
(TOWN SEAL)
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OF`FICE `OF THE TOWN CLERK SOFD(,��
Town of Southold �® �QG Application No. :3S'6
Judith T. Terry, Town Clerk • _r._ .
.0 1 Residential
Town Hall, 53095 Main Road
P. O. Box 1179 u' etA ► `' Non-Residential
Southold, New York 11971 O Telephone ":4441,-;--,14 0-
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE JULY j, I Q r'
OWNER NAME: PYv). H - Geta ,(TP-
OWNER MAILING ADDRESS: f3O . -'7 1 0
CV"' C406 - di.P"( q C
OWNER PROPERTY ADDRESS: / 2 cr g offbt a 1
&!Jr ii-e®c el c
OWNER TELEPHONE NUMBER: 77, 4 74-1f2-
TAX
-1f2TAX MAP NO. : Section 1 l 6. ® ® Block 0 2. 0 0 Lot 0 0 6, 00 6
CROSS STREET: ashy tLo,g-j)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ) New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: WVaf )Ce (71 b,. 010011PeD ov7 APR•t t igk7)
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.)
See I}?7AGi eD
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Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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STAIR i POLEC- 1 MAP OF 0P1 rT '
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LTHORIZED ACTION OR A6BIY1pv. L • GILLENI— a SURVEY ISA OLATION OF •
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i CTION 7209 OF THE W YORK STATE .
EDUCATION LAW - -
Cit/PIES OF THIS SURYC A P NOT REARING : �.. 1 4!• ,b L . G ! LLEJ\J` t�v
G ARANTEES INDICATED R N SHALL RUN --V T
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OM THE SURVEY • ' '
IS PREPARED, AND ON HISAl LF TO TILE / - -
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T THE ASSIGNEES OF THENDI 11 4r6T1-
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