HomeMy WebLinkAboutSimpson OFFICE OF THE TOWN CLERK . c.31FUe
Town of Southold O mow; c�
Judith T. Terry, Town Clerk ,
Town Hall, 53095 Main Road Q �k .,ti ;
P. O. Box 1179 � cn � � .
Southold, New York 11971 •
Telephone - ®" Nt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation- Permit No. 532 Residential x
Non-Residential
Fee $ ,10.00
Septic Cesspool x
NAME OF OWNER: Theodore R. Simpson
OWNER MAILING ADDRESS: P.O. Box 239
Southold, New York 11971
OWNER PROPERTY ADDRESS: 125 Brigantine Drive
Southold, New York 11971 '
OWNER TELEPHONE NUMBER: 516-765-5523
TAX MAP NO. : Section 71 Block 2 Lot 1R
CROSS STREET: Harbor Lights Drive
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
000,41.14,:erc .
Judith T. Talry
Southold Town Clerk
DATE: December 14, 1987
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(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c0FO(,- = c��2
Town of Southold �® CQG Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road „,„ Residential
P. O. Box 1179 v' fir Non-Residential
Southold, New York 11971 ' ®���`
Telephone "i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /2`//.0/P7
OWNER NAME: ---Ig. v�ote-
OWNER MAILING ADDRESS: /2 / 7 /1
0)( 23 .7 Sev-Tf/ / /Y./ //I,/
OWNER PROPERTY ADDRESS: �Gc
OWNER TELEPHONE NUMBER: _4-7, —
TAX
, —
TAX MAP NO. : Section "7/ Block Lot / r
CROSS STREET: W/4-/.�j;o✓z
TYPE OF SYSTEM: Septic Tank New Existing
Cesspools New Existing d
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: q
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.)
/ A
r,Signature of A. .licant
RECEIVED BY:
RECEIVED own Jerk's ffice
DATE: lace4, ;eu
Town Clerk Southold
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