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VanBourgondien
JUDITH T. TERRY Town Hall, 53095 Main Road TOWN CLERK p rZ P.O. Box 1179 REGISTRAR OF VITAL STATISTICS Southold, New York 11971 MARRIAGE OFFICER ®` ®�' ,t Fax (516) 765-1823 - ®1 �D � Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3114-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner VAN BOURGONDIEN, PHILIP Mailing Address 1 P. O. BOX 1211 Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address 1 1285 CALVES NECK ROAD Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-765-1265 Tax Map No. section 63.00 block 7 lot 36.000 Cross Street HARPER ROAD Date Of Last Pump Out 0/00/75 Issue Date: 9/23/93 Judith T. Terry Southold Town Clerk (TOWN SEAL) c• `-s OFFICE OF THE TOWN CLERK cSFO(,(" Town of Southold CQG' , Application No. /) Judith T. Terry, Town Clerk ♦ .47.„1- is Town Hall, 53095 Main Road y -'� ti $10. 00 - Residential P. O. Box 1179 -,:j � $25.00 - Non-Residential Southold, New York 11971 00 .0�,•��` .x, 41 Telephone .( (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $/0,00— DATE /4',d0DATE 4Jrjq73 OWNER NAME: PN, L, P (/A Al BO u &o"I.l)/F N OWNER MAILING ADDRESS: ) 0, fro)( J?./l Svvr/-IOLb , NM // 97/ OWNER PROPERTY ADDRESS: J2 8.5.- C/1 L VE: A/Ec_k /?b J©vY/1OL2 / NM //77/ OWNER TELEPHONE NUMBER: (- 7',_$-/2 C.5 TAX MAP NO. : Section 4 3- 7-3C Block Lot • CROSS STREET: NAR PER AD TYPE OF SYSTEM: Septic Tank New Existing .. Cesspool I/ New Existing V . Residential V Non-Residential DATE OF PREVIOUS PUMP-OUT: 1 9 75 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 pplicant RECEIVED BY: ( �,,e-z, _ Town C erk's Office DATE: G) „ . , .5-az casSPOOL 0 m 6 EASE -C 44-P -� (-1S • / f /+o ' Vl.s . mac/ Ro,L.v