HomeMy WebLinkAboutOlsen (2) OFFICE OF THE TOWN CLERK •���FCD
Town of Southold
Judith T. Terry, Town Clerk `
Town Hall, 53095 Main Road ��. ='
P. O. Box 1179 u?
Southold, New York 11971 p -
Telephone :_
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK,-or CESSPOOL
Operation Permit No. 296 Residential - x
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Harold W. Olsen
OWNER MAILING ADDRESS: Box 953
Mattituck, New York 11952 •
OWNER PROPERTY ADDRESS: Dean Drive
Cutchogue. New York
OWNER TELEPHONE NUMBER: 516-734-6915
TAX MAP NO. : Section 116 Block 4 Lot 20
CROSS STREET: - New Suffolk Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: December 1986
t 444 tis...4.4041r."
Judith T. Terr
Southold' Town Clerk
DATE: May 4, 1987
(TOWN' SEAL)
II IIS
OFFICE OF THE TOWN CLERK c,�FFt/C =
Town of Southold �� �Q ' Application No.(9 ,6
Judith T. Terry, Town Clerk s ,
,� �� � I Residential
Town Hall, 53095 Main Road - �x
P. O. Box 1179 �� �;' Non-Residential
®
Southold, New York 11971 `;'*"$ `�
Telephone _ 1 0 /
�`
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 1/A9 4.,
•
OWNER NAME: o dl 5 A
OWNER MAILING ADDRESS: /30 X 9'5- '3
OWNER PROPERTY ADDRESS: C�—�''2- � �✓it-c�--�� --6-oc2� g /
•
OWNER TELEPHONE NUMBER: -2 '3 .4/ - 6 9 /
TAX MAP NO. : Section 1/6 Block '9 Lot 6
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
e '
Cesspool Y , New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1 / G
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.)
Signature of Applicant
RECEIVED BY: jx
Tow r Clerk'sffice
DATE: