HomeMy WebLinkAboutGustavson (2) OFF..i:C OF THE TOWN CLERK icOf0 C"
town of Southold Q 0�
Judith T. Terry, Town Clerk „
Town Hall, 53095 Main Road
P. O. Box 1179 .1.1"
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Southold, New York 11971
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Telephone
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 596 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Troy Gustayson
OWNER MAILING ADDRESS: P.O. Box 247
Orient, New York 11957
OWNER PROPERTY ADDRESS: King Street
Orient, New York
OWNER TELEPHONE NUMBER: 516-323-2790 (Home) 516-477-0081 (Work)
TAX MAP NO. : Section 26 Block 1 Lot 30
CROSS STREET: Willow Terrace
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: December 1987
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Southold Twin' Clerk
DATE: February 10, 1988
--(TOWN SEAL)
JOFFICF-OF THE TOWN CLERK G``�Fair
Town of Southold ��JU. CQ Application No. ,S
Judith T. Terry, Town Clerk �'` Residential ><--
Town Hall, 53095 Main Road c z` Ful
P. O. Box 1179 ' � Non-Residential
Southold, New York 11971
"Telephone 5 ?/ J
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation !Permit No.
Fee $ 1
DATE Q (N) Z (
OWNER NAME: -1-12-47(-1 u `) S ' v�b
OWNER MAILING ADDRESS: P.0 • �� 2��
o/2--( ��' t 3''i 15---)
OWNER PROPERTY ADDRESS: fr-I1\)6" S •
o(2-(CN ti l
OWNER TELEPHONE NUMBER: 3-2-7-1):-Y1 (HJ> `rn �O ( (o
TAX MAP NO. : Section � Block t Lot
CROSS STREET: W j!`- k
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing >(
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
S
Signat re of Applicant
RECEIVED BY:
Town erk's ffice
DATE: 1