HomeMy WebLinkAboutWalgo (2) OFFICE OF THE, TOWN CLERK � °""
Town
Town of Southold %Judith T. Terr Town Clerk 1
Town Hall, 53095 Main Road 1 sr
P. 0. Box 1179 �� ,n ` : ,,
Southold, New York 11971 p ``® -; �- •`
- Telephone VO./
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 424 Residential X
- Non-Residential
- Fee $ 10.00
Septic Cesspool x
•
- NAME OF OWNER: Mary Walgo
OWNER MAILING ADDRESS: Box 193
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: Sound Avenue
Mattituck, New York 11952
OWNER TELEPHONE NUMBER: 516-298-8259
TAX MAP NO. : Section 141 Block 3 Lot 10
CROSS STREET: Factory Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Approx. 14 years ago -- 1973
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T. Tor yy
Southold Town Clerk
DATE: September 16, 1987
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TOWN SEAL)
OFFICE OF THE TOWN CLERK �cOFOC,r�'-
Town of Southold �� Application No. qc,2
Judith T. Terry, Town Clerk ` . "\ Residential
Town Hall, 53095 Main Road a -
P. O. Box 1179 * � Non-Residential
Southold, New York 11971 O 0tte_""
Telephone
(516) 765-1801 _ 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ f`Q
DATE
OWNER NAME: MAR R y j(J , Lt G O
OWNER MAILING ADDRESS: D x 03
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OWNER PROPERTY ADDRESS: ifet i77 7 U 4' 1 / 7
OWNER TELEPHONE NUMBER: 9 �
1
TAX MAP NO. : Section /4 / Block 3 Lot /6
CROSS STREET: NiCe_c
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ‘‘_.../ /Z./ ��?fJ� aro
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.)
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Sig ature of Ap)icant
RECEIVED BY: I /fir_ S _11,A A
own—C -rk's Offi .e
DATE:
AIL
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