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HomeMy WebLinkAboutTillistrand OFFICE OF THE TOWN CLERK" cvFF°tire"- Town of Southold Judith T. Terry, Town Clerk Town Hall, 53095 Main Road :' P. O. Box 1179 cn Southold, New York 11971 \` � O •� Telephone ',y`�7 jlye NOI' (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 622 Residential x Non-Residential Fee $ 10.00 Septic Cesspool x NAME OF OWNER: Edward Tillistrand and Marie Tillistrand OWNER MAILING ADDRESS: P.O. Box 1075 Southold, New York 11971 OWNER PROPERTY ADDRESS: 580 Private Road No. 21 Southold, New York OWNER TELEPHONE NUMBER: 516-765-3526 " TAX MAP NO. : Section 78 Block g Lot 38 CROSS STREET: North Bayview Ext. TYPE OF SYSTEM: Septic Tank New Existing Cesspool X New Existing x Residential X Non-Residential DATE OF PREVIOUS PUMP-OUT: Unknown • i. Southold Town Clerk DATE: February 25, 1988 - --- ` (TOWN SEAL) , I arm�I� OFFICE OF THE TOWN CLERK \\FFU`A Town of Southold . �o� . CQ Application No. Judith T. Terry, Town Clerk . Town Hall, 53095 Main Road It.. l Residential P. O. Box 1179 u' _ Wyg Non-Residential Southold, New York 11971 O `® ` " *'STelephone 0.( Y*•-•• (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 9-g Fee $ /d,t d DATE 4/s/4-� OWNER NAME: .---0/(-092 //��tSTr/fA-/ d OWNER MAILING ADDRESS: r. '" X /o 7..r— (-17/4 h I/ ..r—ui//ahI, N-V /,971 OWNER PROPERTY ADDRESS: 5—Cd 11/77 /ed14cv? OWNER TELEPHONE NUMBER: 7(,(r,2J- ? 6 TAX MAP NO. : Section '7 7 Block Lot 3 CIP CROSS STREET: 4.47" TYPE OF SYSTEM: Septic Tank ;/ New Existing " Cesspool V New Existing Residential ✓ Non-Residential DATE OF PREVIOUS PUMP-OUT: LOCATION MAP: Must be attached hereto before permit may be issued. 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