HomeMy WebLinkAboutBuckley (2) „ Town Hall, 53095 Main Road
P.O. Box 1179
' ��yoto Southold, New York 11971
JUDITH T.TERRY "� FAX(516)765-1823
�� TELEPHONE(516)765-1801
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. 1383-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BUCKLEY, KATHERINE
Mailing Address 1 2 GALT COURT
Mailing Address 2
City St Zip MARLBORO NY 07746-0000
Property Address 1 440 ROGERS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 510-505-2538
Tax Map No. section 66.00 block 2 lot 14.000
Cross Street HIPPODROME
Date Of Last Pump Out 0/00/00
Issue Date: 2/14/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.
OEFICE' OF THE TOWN CLERK c��FFO(,� -
Town of Southold Q C' /3Y3
Judith T. Terry, Town Clerk �l/ Application No.
gib; ,-. � ;�
Town Hall, 53095 Main Road �� `� $10.00 - Residential
p. O. Box 1179 c �.¢w %
�„t � $25.00 - Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE _//31/4.
'OWNER NAME: /`4 l HEi2/A/E eGec%BEY
OWNER MAILING ADDRESS: d2 Gi4l 7
. - AM4�t_eeit2o 4/.1 o '?
OWNER PROPERTY ADDRESS: 4'LO / cam' 6e9/
.t�0 Gc' %/`/O/�7 /V .
OWNER TELEPHONE NUMBER: ci7 SO s Ar.
OWNER 3f
TAX MAPO. : Section l0 Block ,2 Lot /
CROSS STREET: "2.40 m ,t)/�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 'S2/
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.)
)(41; ' -
Signature . ' pplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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