HomeMy WebLinkAboutGillispie - yr
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y " Town Hall, 53095 Main Road
P.O. Box 1179
�i! Southold, New York 11971
JUDITH T.TERRY - ��I FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 993-R Residential X Non-Residential
O
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GILLISPIE, CHARLES S.
Mailing Address 1 BOX 267
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2174
Tax Map No. section 23.00 block 1 lot 22.000
Cross Street OLD MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/24/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'k
OFFICE OF THE TOWN CLERK c�VFFO(,I#
Town of Southold C
Q Application No.
Judith T. Terry, Town Clerk ` r i
Town Hall, 53095 Main Road. x -'� Residential
P. O. Box 1179 _ u' Z ' •'
,_,<? �i � Non-Residential
�. 1,1.;-.--.: yr
Southold, New York 11971 O ®
Telephone ' ,
(516) 765-•1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ i 0 9�
DATE /
OWNER NAME: C ' r4 6,2179
OWNER MAILING ADDRESS: 1 X ,--2-407 ) /7 P.y
OWNER PROPERTY ADDRESS: r+,71, /9 c7- kJ; '4'
OWNER TELEPHONE NUMBER: ( 4( v) — A( 7
TAX MAP NO. : Section Block Lot
CROSS STREET: //1/(64.¢__.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: (90 (S q
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.)
‘i
. ,11/4")
Signature of Applicant
RECEIVED BY: '
RE _eaIerk's ffice
DATE: JAN 24
(98-1
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