HomeMy WebLinkAboutTerry (2) JUDITH T. TERRY `
Town Hall, 53095 Main Road
TOWN CLERK '; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ;p j �' ' Southold, New York 11971
MARRIAGE OFFICER ? �!, >' sj Fax (516) 765-1823.;,;)
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OFFICE
Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1582-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TERRY, HOWARD
Mailing Address 1 615 JOCKEY CREEK DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 615 JOCKEY CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3402
Tax Map No. section 70.00 block 2 lot 18.000
Cross Street MAIN ROAD/OAKLAWN AVENUE
Date Of Last Pump Out 0/00/00
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Issue Date: 1/17/91 Judith T. Terr
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�1FO(,�
Town of Southold � 4 _ Application No. /61-02--
Judith T. Terry, Town Clerk �?'c: :�
Town Hall, 53095 Main Road 8 .1-5(- $10.00 — Residential
P. O. Box 1179 cry Z;!$'6 �''�`'` ' h�i
-� � $25.00 - Non-Residential
Southold, New York 11971
Telephone !;?0/ , `j1�� '�•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
O
Fee $ 110,.(2Q-
DATE
0_•
DATE WO U t l UO
'OWNER NAME: F—)DIAmcz_ D /tft -TEM_y •
•
OWNER MAILING ADDRESS: 116 jDc-teE, Y a((=EK. Diads
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OWNER PROPERTY ADDRESS: N ' J C 1 y e.-11C- 0 Q eErttce"lV-
MO IJ R,O N D & Q A KI_A w tJ fF U
OWNER TELEPHONE NUMBER: 7L 5 - 3e-i0-2--
TAX MAP NO. : Section "JO Block `a-- Lot ) 1"
CROSS STREET: � -� f?s_ /0 ae„„_
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool
New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,-g-2- I O
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
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or of distance, approximately, to building and closest road.)
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Signature of Applican
RECEIVED BY: L. C'.cc�
Town Clerk's Office
DATE: acs - ye
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