HomeMy WebLinkAboutVanderbeck (3) Town Hall, 53095 Main Road
P.O. Box 1179
® it ,w®o'�'� Southold, New York 11971
JUDITH T.TERRYTE=1�„�� ,,,•�, 5 6L 765-18010NE
TOWN CLERK
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. 740-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VANDERBECK, WILLARD K.
Mailing Address 1 MINNEHAHA BLVD.
Mailing Address 2 -
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MINNEHAHA BLVD.
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2146
Tax Map No. section 87. 00 block 3 lot 56.000
Cross Street OPECHEE ROAD
Date Of Last Pump Out 0/00/85
Issue Date: 6/23/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK CO Fair '
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Town of Southold �� CQG' , Application No. -7'1"
Judith T. Terry, Town Clerk /
�•G 7 Residential ./
Town Hall, 53095 Main Road a tp. mss .
P. O. Box 1179 cn ` ,,' i �� Non-Residential
Southold, New York 11971 O'4044--
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Telephone ,( �►� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 6123/2',
OWNER NAME: �L 1,491Z,t� 1.44/1)11:(?)3T 1.<
OWNER MAILING ADDRESS: /4//V4/25//4-,4/4-- &LV1 _ -
cli7/aLD ; M /1971
OWNER PROPERTY ADDRESS: /1/0/4---71--/(11-1-,} /34I/•/),
c/T/ 4!J, N K //6?7/
OWNER TELEPHONE NUMBER: 7S - 2/2/C
TAX MAP NO. : Section ri Block 5 Lot Z
CROSS STREET: Q1F/5'CHE RD -
TYPE OF SYSTEM: Septic .Tank New Existing /
Cesspool V New Existing x/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: APPA? 9?(• - 3 YR..
LOCATION MAP: Must be attached hereto before permit may be issued.
CArr,c 5') (Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
i
RECEIVEco IIx ' J
— Town CI k's Offi e
DATE: JUN 13
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