HomeMy WebLinkAboutRogers (2) JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK r j P.O. Box 1179
- Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
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MARRIAGE OFFICER C O �. Fax (516) 765-1823
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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. 1937-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROGERS, JON
Mailing Address 1 856 MIXSELL STREET
Mailing Address 2
City St Zip EASTON PA 18042-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 215-258-9072
Tax Map No. section 31 .00 block 8 lot 4.000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �c.0FUi %,
Town of Southold % CQ - Application No. ,' 3'
Judith T. Terry, Town Clerk 5 ,i 1 ik
Town Hall, 53095 Main Road ''� $10.00 - Residential
P. O. Box 1179 crs - ' -x ` $25.00 - Non-Residential
Southold, New York 11971 OtiJ®W •1$
Telephone 0j ��el ''•
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
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APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
I
Fee $ • 1
1 DATE b 1 a 2------
OWNER NAME: l'a& TcS)G•�21r-S 1
OWNER MAILING ADDRESS: g 1 �` pc s...,21/ S
F S SMI; ate. ; (10ifZ
- ` .. OWNER PROPERTY ADDRESS: M 6 1 '-'0alli4
sf L ).-vM u '( f (c1 c(
OWNER TELEPHONE NUMBER: `7._ / C; — 2 5 90 7 2.—
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TAX MAP NO. : Section a! Block e" Lot /*/
'CROSS STREET:
TYPE,OF,_SYSTEM: 'Septic Tank `= --- - - New Existing
Cesspool New Existing p<
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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.)
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. - Signature . App 'cant
RECEIVED -
,BY: . - - -- - -- .__._._. . .... . ---
Town Clerk's Office - "
DATE.:
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