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HomeMy WebLinkAboutSander OFFICE OF THE TOWN CLERK cOf r Town of Southold Judith T. Terry, Town Clerk qtr $ • ift Town Hall, 53095 Main Road t 'tRAV P. O. Box 1179 u'a � > � `• Southold, New York 11971 s �- Telephone ` .�1 (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 368 Residential X Non-Residential Fee $ 10.00 Septic' Cesspool X NAME OF OWNER: Samuel Sander OWNER MAILING ADDRESS: Box 89, Old North Road Southold, New York 11971 OWNER PROPERTY ADDRESS: 3635 '01d -North Road Southold, New YOrk OWNER TELEPHONE NUMBER: 516-765-2599 TAX MAP NO. : Section 51 Block 2 Lot g CROSS STREET: Mt. Beulah Avenue TYPE OF SYSTEM: Septic Tank New Existing Cesspool X New Existing x Residential X Non-Residential DATE OF PREVIOUS PUMP-OUT: 4/16/87 Judith T. Terry Southold Town Clerk DATE: July 29-, 1987 (TOWN SEAL) _- OFFICE C3�r 'TFi� TOWN CLERK iC���r0( - Town of Southold h.,�Q % Application No-1/434d Judith T. Terry, Town Clerk r` -` �'� Residential A" Town Hall, 53095 Main Road o . ,_r P. O. Box 1179 1723 � � �' Non-Residential Southold, New York 11971 Telephone (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICAT ION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ j©, QO DATE /7 1 qg7 OWNER NAME: L OWNER MAILING ADDRESS: &J RV , �o 8` OWNER PROPERTY ADDRESS: 3c, 3_s-- ©LD N O P-.1-l-I Pp, 0Utp ry71 OWNER TELEPHONE NUMBER: 76.5'_ 5 �7 TAX MAP NO. : Section5/ Block Lot CROSS STREET: Air,, E. u G4- vE - TYPE OF SYSTEM: Septic Tank New Existing Cesspool ✓ New Existing I/ Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: y /i (F7 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: Town Clerk's Office DATE: • A............,.40............n....••••.,.......-4........r.4........A.•••,.........................64Mery, ...•44.7-4.4.441.41.-.444pso.".'44‘`'.......`''''''''''''''''''''.-'-' •:-‘. , I ,. ..... , 1 . . . , ''-AppliCant shall prepare peat1y drafrn sketch. See Department of Health i instruction notes for.raid aid in making sketch and completing application form. ,,.. .; • - ' " ' "• ••••••• ••• i 4...... r\I 4........4••••• ••••••............-..-e....:......---..`..` . .7.....,.11'.....) . 1 .0;i ..'•....44,'1...L 4 F - I 4 .....i. - ",:C f. 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