HomeMy WebLinkAboutSimonson OFFICE OF THE TOWN .CLERK ' 'v F J4-
Town of Southold - CDG
Judith T. Terry, Town Clerk ,
Town Hall, 53095 Main Road ; o
P. O. Box 1179 cr2 77471triS ' •
Southold, New York 11971
Telephone __.�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 72 Residential xx
Fee $ 10.00 Non-Residential
Septic Cesspool xx
NAME OF OWNER: Nellie Simonson
OWNER MAILING ADDRESS: 1650 Strohson Road
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: 1650 Strohson Road
Cutchogue, New York 11935
OWNER TELEPHONE NUMBER: 516-734-5258
TAX MAP NO. : Section 103 Block 10 Lot g1
CROSS STREET: Baldwin Place
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool xx New Existing xx
Residential xx Non-Residential
DATE OF PREVIOUS PUMP-OUT: August 1986
Judith T. Terr
Southold Town Clerk
DATE: September 30, 1986
I
(TOWN SEAL)
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OFFICE OF THE TOWNCLERK •••VFFO
Town of Southold CSG'_. Application No. ,
Judith T. Terry, Town Clerk % 0
Town Hall, 53095 Main Road . * " Residential
P. O. Box 1179 �' � , :' Non-Residential
Southold, New York 11971 O Y �
Telephone ®1jrid.. Y‘‘f; . '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ Jt
DATE 7-`� `(19
OWNER NAME: //AEU/C 5.7727 QNS' d•'✓
OWNER MAILING ADDRESS: /6',-C-6 STe4/-/-co.�c.1 c� c
C6161 1 y
OWNER PROPERTY ADDRESS: 4-7 �-..
OWNER TELEPHONE NUMBER: -7,S 9/---
TAX
TAX MAP NO. : Section /sO 3 Block /6 Lot 2/
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool .7(.._ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4c) C ( q 426
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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)21/Y7-2;14-ef-
Signature
of Applicant
RECEIVED BY:C7 tiytcec
Town C rk's Offi }e
DATE: Li /a tec>2 R_ l F
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