HomeMy WebLinkAboutGoubeaud ,1 L 'y�
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un � Town Hall, 53095 Main Road
+Q,04® N®s-��� P.O. Box 1179
1 �,#' Southold,New York 11971
JUDITH T.TERRY ,,ir�,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. 1545-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GOUBEAUD, CHARLES E.
Mailing Address 1 1280 TOWN HARBOR LANE
Mailing Address 2 BOX 82
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1280 TOWN HARBOR LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3224
Tax Map No. section 64.00 block 5 lot 10.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0100/43
Issue Date: 10/04/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •SvTFO(,r
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Town of Southold ' Application No. /3
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 8 '` r< $10.00 - Residential
P. O. Box 1179 cn ' $25.00 - Non-Residential
Southold, New York 11971 O'�10-1/
Telephone 0.(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. is-5-5/5-
Fee $
S5/.-
Fee $ /' %-
DATE /O - -9d
•
'OWNER NAME: C /` IEC E. Go V B
OWNER MAILING ADDRESS: ( 0 °-OW-kr 'IMMO g 2 s7Cc -
OWNER PROPERTY ADDRESS: , P .
OWNER TELEPHONE NUMBER: % c---3 2). 4-
TAX MAP NO. : Section 4/ Block 3 Lot /
CROSS STREET: ` Vl /2
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /'9.
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: Oir
Town Clerk's ffice
DATE: /0 ` -a -�d
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