HomeMy WebLinkAboutShipman Town Hall, 53095 Main Road
�® O1 P.O. Box 1179
x_12 1\fo 1. Southold, New York 11971
JUDITH T.TERRY
��� 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. 1248-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SHIPMAN, JOE
Mailing Address 1 985 ELIJAH'S LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1
Property Address 2
City St Zip 00000-0000
Owner Telephone No. 516-298-4619
Tax Map No. section 108.00 block 4 lot 7.005
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/22/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I III •
OFFICE OF THE TOWN CLERK 'c�\\VFD(,r.
Town of Southold Q C'O Application No. J02,V7
Judith T. Terry, Town ClerkRigtyy
Town Hall, 53095 Main Road is -� $10.00 - Residential ✓
P. O. Box 1179 ,k. t { i �� $25.00 - Non-Residential
Southold, New York 11971 O # ��
Telephone �( n
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /0,
Fee $
DATE
OWNER NAME: � )Yl 7P ' / f j �6-'y') • •
OWNER MAILING ADDRESS: 1 4 1L'd ,4474, '4v
OWNER PROPERTY ADDRESS: yY1.P -
OWNER TELEPHONE NUMBER: 017/
TAX MAP NO. : Section r7 ;p Block Lot ,),�j
CROSS STREET: � (-v,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1/ New Existing i/
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: ) tJ-f /;;' ?6U )6 7 o f
LOCATION MAP:( Must be attached hereto before permit may be issued.
sl (Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
-0 f
(-7q
,i1-° N
f (/) Signature of App icant
RECEIVED BY:
Town Cllerk'ss Office
DATE: Q-47-EY