HomeMy WebLinkAboutWilshusen Town Hall, 53095 Main Road
P.O. Box 1179
r so' Southold, New York 11971
JUDITH T.TERRY �� �ii��! FAX(516)765-1823
TOWN CLERK X1141 TELEPHONE(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. 1163-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New ' Existing X
Name Of Owner WILSHUSEN, WALTER
Mailing Address 1 45 CENTER STREET, RD 2 BOX 72A
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 45 CENTER STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8601
Tax Map No. section 123.00 block 2 lot 6.000
Cross Street MARRATOOKA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/20/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK S\\VFQL -
Town of Southold c� � CQG' Application No. //63
Judith T. Terry, Town Clerk ° �� �iy r=
Residential
Town Hall, 53095 Main Road o
,p. O. Box 1179 u' Non-Residential
Southold, New York 11971 O � {`,.�0 ��`,
Telephone _ j
(516) 765-1801
• TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
•
OWNER NAME: wALTE' s) k ff /
OWNER MAILING ADDRESS: its ctivraz, sr AV, a Box '22i4
HAT° /7 wdr) ,y) /119-5` ...
OWNER PROPERTY ADDRESS: 5'40.g-
OWNER TELEPHONE NUMBER: �fe- (p®/
TAX MAP NO. : Section /23 Block 0Z- Lot 6
CROSS STREET: c' ,e/V7zQ, 7
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential J Non-Residential
DATE OF PREVIOUS PUMP-OUT: .07- PPIA,
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.)
' - R
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: JUS 2 8 1:14,
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