HomeMy WebLinkAboutVanderbeck c.
° % Town Hall, 53095 Main Road
�_ '�, ���'' P.O. Box 1179
® ®��' Southold, New York 11971
JUDITH T.TERRY '_ ®Z ' otTELEPHONE
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TOWN CLERK i (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. 886-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VANDERBECK, ARTHUR M.
Mailing Address 1 845 PINEWOOD ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 845 PINEWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6861
Tax Map No. section 110.00 block 3 lot 9.000
Cross Street SOUTHERN CROSS ROAD
Date Of Last Pump Out 1/07/85
Issue Date: 10/17/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'-� 4FIICE OF THE TOWN CLERK c31FO(,1r�'- /
Town of Southold Q ., A lication No. lY
Judith T. Terry, Town Clerk pp
Town Hall, 53095 Main RoadA _�',t -c Residential
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P. O. Box 1179 ' V K.*
hzi �� Non-Residential
Southold, New York 11971 O ®.* -
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Telephone ( 1
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE /61/3/ii
OWNER NAME: Ak 1p )e 17Ply J? U�
OWNER MAILING ADDRESS: g4•- PIgFLI4J6-a,D �,
a t l-10 911E
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 13 '- 6 ifr4-/
TAX MAP NO. : Section Block 3 Lot
CROSS STREET: ® t'�D-/EAt1 (czp,5,s OD-
TYPE OF SYSTEM: Septic Tank New Existing" X
Cesspool )C New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1/7/16 -
LOCATION
/7/16LOCATION 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.)
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Signature of Applicant
RECEIVED BY: e1,a, Q. e- J
REcc 3 Town Clerk's Office
DATE: 01-i-1- 1 )ges
ThWn Clerk Si 1rI aid
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