HomeMy WebLinkAboutGilles .410
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® ' $ Town Hall, 53095 Main Road
y '% P.O. Box 1179
,�'' Southold, New York 11971
JUDITH T.TERRY r= �., /i�, I i/, FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1478-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GILLES, E. P.
Mailing Address 1 BOX 393
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MIDDLE ROAD (ROUTE 48)
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8432
Tax Map No. section 122.00 block 1 lot 2.000
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/80
Issue Date: 6/07/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
o
OFFICE OF THE TOWN CLERKS�FFOut -
Town of Southold � ,_ BOG Application No. / WV
Judith T. Terry, Town Clerk . y
Town Hall, 53095 Main Road �u;= :� $10.00 - Residential
P. O. Box 1179 = t+° i ; $25.00 - Non-Residential
Southold, New York 11971 O 0;;;;
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ) O Gro
DATE
OWNER NAME: EE- ? C---1 / •
OWNER MAILING ADDRESS: q
M )9 -T 7-' y �v"eL, -, < ! /9 s~z-
- - OWNER-PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: �j ' v FCi-4/ 3 L--
TAX MAP NO. : Section J Yil Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: I I A
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.)
Si nature of App icant
RECEIVED BY: - OCOA `� -
I _
JUN We w 95lerk's Office
DATE: 11= aabt'i
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