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HomeMy WebLinkAboutGillispie .ti cC 14° JUDITH T. TERRY % O L Town Hall, 53095 Main Road TOWN CLERK ` G T P.O. Box 1179 REGISTRAR OF VITAL STATISTICS Cly • Southold, New York 11971 MARRIAGE OFFICER ®` • Fax (516) 765-1823 —,y®1 jfit ��® � Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1635-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner GILLISPIE, DAVID Mailing Address 1 221 NORTH ROAD Mailing Address 2 City St Zip GREENPORT NY 11944-0000 Property Address 1 221 NORTH- ROAD Property Address 2 City St Zip GREENPORT NY 11944-0000 Owner Telephone No. 516-477-9684 Tax Map No. section 35.00 block 2 lot 7.000 Cross Street WIGGINS LANE Date Of Last Pump Out 0/00100 Issue Date: 3/05/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK c3IFD� ''• - Town of Southold � C Application No. /6 OS Judith T. Terry, Town Clerk $10.00 - Residential Town Hall, 53095 Main Road _ -< P. O. Box 1179 cnY � z ., ,'�� d � $25.00 - Non-Residential Southold, New York 11971 O "® .vim Telephone *Oj �•.; ,/• �` (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION • for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ 1,0 DATE �� OWNER NAME:" L l S • OWNER MAILING ADDRESS: 2-2- OWNER PROPERTY ADDRESS: , OWNER TELEPHONE NUMBER: (-tfl.(1 CLCh%Cr TAX MAP NO. : Section Block Lot CROSS STREET: L.JLc-i 1 >r-t S TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: a.-,C. 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.) Signature of Applicant RECEIVED BY: '. Total, its Office DATE: ���� ©5 19e1 c3 4c.,9 -- - - -- - - -- - - -- - - - -- - - - - - -- --- ---- ---- ---- - ---- -- ----- -- - - - - - - - - ----- - - _ _ _ _ _ _ _ _ q0 cc,$__cra - -- -- - - - ----- - \(; c,q(