HomeMy WebLinkAboutOthen z Town Hall, 53095 Main Road
��$ P.O. Box 1179
®igi' � �s� Southold, New York 11971
JUDITH T.TERRY = „i„/ r'��� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 1263-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner OTHEN, ROBERT AND MARGARET
Mailing Address 1 395 MEADOW LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 395 MEADOW LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5888
Tax Map No. section 116.00 block 2 lot 21 .000
Cross Street CASE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/11/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK __ c.SFOLA, -
Town of Southold � h ,# ��G Application No. /6263
Judith T. Terry, Town Clerk f.
_ y
Town Hall, 53095 Main Road i -' 7 $10.00 - Residential '✓
A
P. O. Box 1179 cn - Kitt $25.00 - Non-Residential
Southold, New York 11971 z`�0 �`,
Telephone j •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT _ __
APPLICATION'
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No.
00
Fee $ /O ✓
DATE Ie -5 '. 8y'
OWNER NAME: ICe,-C AllOater- •{4. 0-6en •
•
OWNER MAILING ADDRESS: 95 P1 eQCdtQ e
amu _ i • s
OWNER PROPERTY ADDRESS
OWNER TELEPHONE NUMBER: (.5) (0)77\.3(1-.j 888
TAX MAP NO. : Section 6Block ,."2i Lot �i l
CROSS STREET: 1` arbv_s2-.4-01-
TYPE
OF SYSTEM: Septic Tank / New Existing
Cesspool V New Existing v
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: I� y j� g (e4 # figir '
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:
Town Clerk's Office
DATE:
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