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HomeMy WebLinkAboutPlock • OFFICE OF THE TOWN ,CLERK . FO ` Town of Southold O��F �CD Judith T. Terry, Town Clerk �� •_ �' Town Hall, 53095 Main Road 4N P. O. Box 1179 Southold, New York 11971 Q `00" - Telephone (516) 765-1801 f'- TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 264-- Residential X Non-Residential Fee $ 10.00 Septic Cesspool X NAME OF OWNER: Anna K. Plock OWNER MAILING ADDRESS: 945 Hobart Road Southold, New York 11971 OWNER PROPERTY ADDRESS: 945 Hobart Road Southold, New York 11971 OWNER TELEPHONE NUMBER: 516-765-3203 TAX MAP NO. : Section 64 Block 2 Lot 6 CROSS STREET: L'Hommedieu TYPE OF SYSTEM: Septic Tank New Existing Cesspool X New Existing X Residential X Non-Residential DATE OF PREVIOUS PUMP-OUT: Approx. 1984 e0r9-4414 7/.-.04 .07. { " I Judith T. Terry Southold Town Clerk DATE: April 7, 1987 (TOWN SEAL) ji • V.. OFFICE OF THE TOWN CLERK ���FFD�, = Town of Southold 'S C'� Application No. Judith T. Terry, Town Clerk o`�(� Town Hall, 53095 Main Road Residential rye }kapt P. O. Box 1179 ,"gfA �:: tri �• Non-Residential Southold, New York 11971 O t !$ Telephone _ 4 lac'. Ni\-• (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ DATE OWNER NAME: /,Viy',4 :,' ,C. OG jc OWNER MAILING ADDRESS: 9'15- //0,65/9 ,e7- ,j0- Soci 7-fie z d OWNER PROPERTY ADDRESS: 94/5 /1023.09-4) p. ®v 775!©/4� OWNER TELEPHONE NUMBER: 62/k--- 2 ®— 6-3 TAX MAP NO. : Section ,47 Block 2 Lot LO CROSS STREET: / 1V-0 , - TYPE OF SYSTEM: -Septic Tank New Existing Cesspool X New Existing Residential x Non-Residential DATE OF PREVIOUS PUMP-OUT: -(1.-" /9P-/ LOCATION MAP: Must be attached hereto beforepermitmay be issued. - (Locate building and system; give north arrow and feet of distance, approximat1ly, to building and closest road.) -(7'/&-CIL Signature of Applicant RECEIVED BY: Town erk's O Tice DATE: .; /k/ fsv iN Qin A ' //cwlf 14Fl/