HomeMy WebLinkAboutPettersen A'0.0
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Town Hall,
53095 Main Road
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+` P.O. Box 1179
`�®O.� 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. 1032-R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
New Existing X
Name Of Owner PETTERSEN, THOR & MARY
Mailing Address 1 P. O. BOX 260
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 JACKSON LANDING ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-96113
Tax Map No. section 113.00 block 6 lot 1 .000
Cross Street COX NECK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/23/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �� FO
Town of Southold %c31 �C'I' /0 3�
, i , _, . OG', Application No.
Judith T. Terry, Town Clerk ��x. >r:' i 'i-.. y
Town Hall, 53095 Main Road 7 "''-� : :< Residential
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P O. Box 1179 z`., .w }„% ,�; Non-Residential
Southold, New York 11971 O ® O� .�S
Telephone / , �� °°
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(516), 765-1801 - - - - - - -
' TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • -: - - - - -
DATE - � /o9c3 ` K _.
OWNER NAME: (t.2 M R., q 2 ; 1—� tz.s e, k)
OWNER MAILING ADDRESS: P. . 13 e '- �. 4., £
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OWNER PROPERTY ADDRESS: 4 y-CCsoiti .' L. 4--WV D i A/ C--' R ()
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OWNER TELEPHONE NUMBER: 7 g' - 1C Li 3 {
TAX MAP NO. : Section /(9 Block Ca Lot
CROSS STREET: G4-- '
TYPE OF SYSTEM: Septic Tank V New Existing V
Cesspool New Existing
Residential Ni Non-Residential
DATE OF PREVIOUS PUMP-OUT: (V D &
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.)
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Signature of Appy an _�
RECEIVED BY:. .l.XJ
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Town Clerk's Office -
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