HomeMy WebLinkAboutSanford JUDITH T. TERRY ��`' --7N7.40#.4\
Town Hall, 53095 Main Road
TOWN CLERK s• � �}i��� �'
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � a �' Southold, New York 11971
MARRIAGE OFFICER ;so ��� Fax (516) 765-1823
� x- �� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1700-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SANFORD, JEAN
Mailing Address 1 LOCUST LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 LOCUST LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5426
Tax Map No. section 64.00 block 2 lot 55.000
Cross Street KORN ROAD AND L'HOMMEDIEU
Date Of Last Pump Out 0/00/00
Issue Date: 6/04/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OF ICE„f .)F-THE TOWN CLERKS�FFa/re -
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Town of Southold Q ' , Application No.
Judith T. Terry, Town Clerk �
Town Hall, 53095 Main Road i -� _,, w -'� I $10.00 - Residential
P. O. Box 1179 _ a i; '' ' : $25.00 - Non-Residential
Southold, New York 11971
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.Telephone( NeW0 '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
I APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 73/7 o2j /7/9/
OWNER NAME: Ji44/ 4_ S v";T.p-ci(
OWNER MAILING ADDRESS: S ✓ / 4-4/G
SocTA (cL 1 A/y,
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: MS' 5 .�4:.
64_ a -- sem _
TAX MAP NO. : Section / Block Lot 5-6 -67
CROSS STREET: 9J2/�i.e_-h Cko
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool d-- New Existing
Residential 1.-- 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.)
Signature o Applicant
RECEIVED BY:
Town Clerk's Office
DATE: •
9j1)2A-4 °
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