HomeMy WebLinkAboutTalbott 4614 F Our
Iv) `Z Town Hall, 53095 Main Road
/, P.O. Box 117 9
`��� ►� Southold, New York 11971
JUDITH T. TERRY
TELEPHONE
TOWN CLERK (516)765-1801
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. 1100-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TALBOTT, JO ANN L.
Mailing Address 1 P. O. BOX 194
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 2915 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6558
Tax Map No. section 104.00 block 13 lot 10.000
Cross Street VANSTON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/09/89 Judith T. Ter
Southold Town Clerk
(TOWN SEAL)
1
• ..,
i- OFFICE OF THE TOWN CLERK �cl\fF(kir -
Town of Southold , D,% r CQA% Application No. /1 0 0
Judith T. Terry, Town Clerk 4 a
Town Hall, 53095 Main Road - .� �. :'� Residential
P. O. Box 1179 cr3 tAt, 4"4 5 •• Non-Residential
Southold, New York 11971 O ®,'�. ,f:.O�'••$
Telephone �! �%
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE '` •' 1'
G
OWNER NAME: de) N/A/ L , 74L /sar
OWNER MAILING ADDRESS: Pi 0 , /7 � / Q' )"
P`ie-C,--0,6// C. /t4 L/ i
OWNER PROPERTY ADDRESS: ;6— /11, l / PT Fc
2/Li
OWNER TELEPHONE NUMBER: 7 -%
TAX MAP NO. : Section / 0 5/ Block R, Lot -----A-2- /O
CROSS STREET: f\--- 4- 4/ /4-6 d- .
TYPE OF SYSTEM: Septic Tank v New Existing
L.
Cesspool . ' New Existing v
�
Residential 1.-. Non-Residential
DATE OF PREVIOUS PUMP-OUT: /51-1 -f AAA"— rsti 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.)
0 " /
-717V)& / im //t>
g . .ture (
Siof Applicant
RECEIVED BY:
/ own Clerk's Office
DATE: Sl J 4
y
- _SUFF.CO:HEALTH DEPTe APPROVAL 1,44,.9.-140;.-,,
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TITLE
CERTIF. 17-14'4e.t•io- t 75-04450 TUT,O.d GU:i. . - P...E NOT TRAssfER '; -
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