HomeMy WebLinkAboutPeterson rri Town Hall, 53095 Main Road
P.O. Box 1 l79
® �i ,�/ Southold, New York 11971
JUDITH T.TERRY — 1 . fol°l TELEPHONE
TOWN CLERK �'••�i��/0 (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 . 914-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner PETERSON, CHARLES
Mailing Address 1 PETERSON, ELIZABETH
Mailing Address 2 P . 0 . BOX 123
City St Zip PECONIC NY 11958-0000
Property Address 1 3645 MILL LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-1654
Tax Map No . section 67 . 00 block 2 lot 11 . 000
Cross Street SOUNDVIEW AVENUE
Date Of Last Pump Out 11 /00/84
Issue Date: 11 /09/88 Judith T . Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK S�FFDK�
Town of Southold � C'0 = Application No. /`5`
Judith T. Terry, Town Clerk �` ► •
Town Hall, 53095 Main Road F. Residential
P. O. Box 1179 cn „Wn , Non-Residential
Southold, New York 11971 Q "® `;� O •'`�
Telephone �j `�► '�
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL '
Operation Permit No. '
Fee $ • .
DATE 0'1•
OWNER NAME: Ok6-5. car- 1 0 �. �r�� '� a �i-•-i
OWNER MAILING ADDRESS: P•O'. eo•7c'
Fe e-0�1 c q LE 151
Y
OWNER PROPERTY ADDRESS: 3, .�- /'
i,opt•° . •[ L�'S
OWNER TELEPHONE NUMBcR:
bV eoli L Sfk.o Few 117 Sk erkc r. .
TAX MAP NO. : Section 7 Block Lot
CROSS STREET: �1 V� �"- �- S e_, Y cJ��. CY--p 9 w►`,` kR
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New ' Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: -t
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.)
0/41,1L
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: - •
1 ''''' 11 ( :i „,V7-1-%,
-
411 1 '' '''.1‘`\
1: jli .l ( �\ 1
, i 1 f \i\
®� �� I ' I4\
� G r f
b
I, ;
,