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HomeMy WebLinkAboutBuckley _ a T~?� JUDITH T. TERRY 2• Town Hall, 53095 Main Road �' � ��- �- _ ; TOWN CLERK ' P.O. Box 1179 REGISTRAR OF VITAL STATISTICS , -9 Southold, New York 11971 - c d *� Fax (516) 765-1823 MARRIAGE OFFICER ' 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. 1603-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner BUCKLEY, DONALD A. AND MIRIAM Mailing Address 1 P. O. BOX 897 Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 1260 WESTV I EW DRIVE Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 516-298-4683 Tax Map No. section 107.00 block 7 lot 13.000 Cross Street BROWER ROAD Date Of Last Pump Out 0/00/00 -� .. Issue Date: 1/17/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) • OFFICE OF THE TOWN CLERK FOut- Town of Southold O� e Application No. /6,(5,5 Judith T. Terry, Town Clerk Town Hall, 53095 Main Road 8 1 .•'T w,�« �`) $10.00 - Residential p. O. Box 1.179 cn t � Southold, New York 11971 � - =_' $25.00 - Non-Residential s Telephone ( (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for - - - - OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ • DATE `fli=c. . l \ ' 1.c f,D' 'OWNER NAME: am._ 1o. d `YV\1 c2 4 -v (\ L-11--."--) • • OWNER MAILING ADDRESS: P VA L_ - - OWNER- PROPERTY ADDRESS: 17__.b r0- W ; r 1 l LD�Z OWNER TELEPHONE NUMBER: IE 1 l® 4 TAX MAP NO. : Section 101 Block 0.1 Lot �^3 CROSS STREET: 1.1I - Zr ,L . ZD_ TYPE OF SYSTEM: Septic Tank New Existing Cesspool X_ New Existing Residential x Non-Residential DATE OF PREVIOUS PUMP-OUT: N '©NJ -2._c 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.) Signaturef A Applicant IP o RECEIVED BY: Town Clerk's Office DATE: • . '''''''' ' ik 1 ,to'C.' 1 c:D JC_ R\._\r 1-\\, 2S' "Z� N L'----7-- ''' c----- -' 4 -\_ '.6' 5‘ 0 6 C n 29 f a 1`vG., c7 F --f,L __ L 1 fl P 2s) / , 0 LA7LS i N 1i= -DZ. i ..?--, l./ 0 e.=SS Pam cL