HomeMy WebLinkAboutGohier OFFICE OF THE TOWN CLERK ``" ' •�4,�FFQ[if(`,-
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179 amu' M . ,.
Southold, New York 11971 ;O �� �!�
Telephone Ol 411l
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 213 Residential X
Fee $ ' 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Virginia M. Gohier
OWNER MAILING ADDRESS: P.O. Box 418
Southold, New York 11971
OWNER PROPERTY ADDRESS: Shipyard Lane
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-2241
TAX MAP NO. : Section 64 Block 5 Lot 27
CROSS STREET: Hobart Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Approximately 2 - 3 years ago.
Judith T. Terry
Southold Town Clerk
DATE: February 3. 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK csk'CFf1(�i
Town of Southold ' Application No.
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Judith T. Terry, Town Clerk �` f' �`
Town Hall, 53095 Main Road ~f. ;* ' } Residential
u, *1` h�i Non-Residential
P. O. Box 1179 �. �:.
Southold, New York 11971 0":7'‘® OR• `�f
Telephone ; .'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: 17'6 C-// i 94 C-6/1
OWNER MAILING ADDRESS: /04;p Eteua P'° 6 tor
ani_o ei h¢tn% I 7
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 79- I
TAX MAP NO. : Section 6 y Block � Lot cza
CROSS STREET: `7 QA
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1 / New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /.1-;c3 -3 r rytg
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.)
L
Sig'( ature o Applicant
RECEIVED BY:
RR: 'own Cle k' Office
(5P---)
DATE: FEB 031987
Town C!erk Southold
47
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