HomeMy WebLinkAboutPeterson (2) tf air
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tz Town Hall, 53095 Main Road
�`� P.O. Box 1179
,ss2� ��®��!'tSouthold, New York 11971
JUDITH T.TERRY -=. ws' i'!•�I TELEPHONE
TOWN CLERIC
(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. 778-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner PETERSON, HENRY P.
Mailing Address 1 68 NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 68 NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5302
Tax Map No. section 44.00 block 1 lot 11. 000
Cross Street ALBERTSON LANE/BAYBERRY ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/04/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'cOFO(r
Town of Southold A Application No.7 71
Judith T. Terry, Town Clerk ‘�� , }s �
Town Hall, 53095 Main Road .4 7 Residential
*7.4-44ry 1,jt'k'3
O. Box 1179 `Y '' hi
� { � Non-Residential
Southold, New York 11971 0 � = 0���•
Telephone ®j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 7 ) d
Fee $ f0 '
DATE Sfrr
OWNER NAME: f&/0 A ( - 7 /2O4)
OWNER MAILING ADDRESS: p /®fl, )-1 R(? l b
So irHoLh, A)y 1IC/ 7/
OWNER PROPERTY ADDRESS: S114
OWNER TELEPHONE NUMBER: 5 7� 5 L3
TAX MAP NO. : Section 1-4-1' Block ( Lot l
CROSS STREET: O75aA) /J& 4B&-0 Lfh(J
TYPE OF SYSTEM: Septic Tank New Existing
/
Cesspool 11 New Existing
Residential ,✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: ^TUFF Jgd
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.)
ignature of Applicant
RECEIVED BY:
Town Cly• 's Offic:'
RECE `: )
DATE: AUG lid
1988
Town Clerk' Southold
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