HomeMy WebLinkAboutTerry 01.214"13
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, Town Hall, 53095 Main Road
O. Box 1179
Y® 1 41 ��r�� Southold, New York 11971
JUDITH T.TERRY ,r r TELEPHONE
TOWN CLERK ""01��� (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. 817-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New - Existing X
Name Of Owner TERRY, ELLIS M.
Mailing Address 1 230 JOCKEY CREEK DR
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 230 JOCKEY CREEK DR
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3198
Tax Map No. section 70.00 block 5 lot 8.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/79
Issue Date: 9/08/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK , ,\FFOCA-
Town of Southold � L0 •• Application No. g/
Judith T. Terry, Town Clerk ,' ; . y )
Town Hall, 53095 Main Road a -at 'F w -� Residential r/
P. O. Box 1179 cry = w, WO Non-Residential
Southold, New York 11971 O ®3_ ,01'
Telephone /9j `)1�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE ,e9- c? --Pc?
OWNER NAME: ea,, S 7;17-e /
OWNER MAILING ADDRESS: ..?a 1f ae/fe ,-,1• O�
k5.1) ./Yy / 7/
OWNER PROPERTY ADDRESS: S/ G
OWNER TELEPHONE NUMBER: f‘`— 76-.5-r-'r379rft)
TAX MAP NO. : Section 719 Block 6— Lot y' ;
CROSS STREET: /97 26
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool / New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /77
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 A. .licant
RECEIVED BY: , 14a, c� dt,
own J'erk's Of ce
RECCE' E®
DATE:
SEP 08 ;1
�, ar Clerk S,;,,r®ld
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