HomeMy WebLinkAboutThomson cecg FDIC
� Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ;�i° TELEPHONE
rO VN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERIC
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 823-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner THOMSON, JAY N.
Mailing Address 1 P. O. BOX 467
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 CLARK ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-2980
Tax Map No. section 51.00 block 3 lot 24. 000
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/09/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK SVFFUL4- '=
Town of Southold O • CQG' Application No. SO2
Judith T. Terry, Town Clerk err y
Town Hall, 53095 Main Road .�� Residential
P. O. Box 1179 Cr3 TO; 74; z Non-Residential
• Southold, New York 11971
Telephone _ j %it
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O •
•
DATE- i
OWNER NAME: c1Q //�/ �//�1304)
OWNER MAILING ADDRESS: Li', ,() , PO 15C
c UG-/Z I/ F L71%
OWNER PROPERTY ADDRESS: C%/, "l4.
OWNER TELEPHONE NUMBER: 7 1/ 9.
TAX MAP NO.,: Section 5/ Block 3 Lot
CROSS STREET: Gi/'`7.
TYPE OF SYSTEM: Septic Tank - New Existing. ,-
Cesspool New - Existing .e 5
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
-// ignature of Applicant
tJ�
RECEIVED BY: - •
Town Clerk's Office
RECEIVED - -
DATE: (\a 9
SEP 09 4 :'.
Ion Clerk Southold • . -
fee-