HomeMy WebLinkAboutStoutenburgh 4040" tEgur41,
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`rv" ;1 Town Hall, 53095 Main Road
P.O. Box 1179
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JUDITH T.TERRY FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1425-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STOUTENBURGH, ROGER
Mailing Address 1 840 PINE TREE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 840 PINE TREE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5114
Tax Map No. section 104.00 block 1 lot 11 .000
Cross Street HORTON LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/19/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �c�lFD(,r r
Town of Southold �, �` L'� Application No. / L1
Judith T. Terry, Town Clerk
w _ ' $10.00 - Residential A0--
Town Hall, 53095 Main Road � �.� : �"W�,
P. 0. Box 1179 z ; $25.00 - Non-Residential
Southold, New York 11971 0
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Telephone ( `�
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
OPERATION PERMIT
SEPTIC TANK or ,CESSPOOL
Operation Permit No.
Fee $
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DATE
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OWNER NAME: OG` " %x;110 ' d
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OWNER MAILING ADDRESS: cy 9_p.051-/,
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: (6?() 7s
TAX MAP NO. : Section Block Lot
CROSS STREET: /7321.,7-0 ,1)
TYPE OF SYSTEM: Septic Tank _ New Existing
Cesspool V New Existing 1/--
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued. .
(Locate building and system; give north arrow and feet
of distance, approximately' , tobuilding and closest road.)
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4 Signature of Appant
RECEIVED BY: . - • _
Town Clerk's Office
DATE: -
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