HomeMy WebLinkAboutBurden (3) 11'ILII lS %
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Town Hall, 53095 Main Road
P.O. Box1179
IT®:11' Southold, New York 11971
JUDITH T.TERRY „'// r" FAX(516)765-1823
TOWN CLERK 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. 1259-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BURDEN, RICHARD AND LORRAINE
Mailing Address 1 2800 OLE JULE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2800 OLE JULE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4286
Tax Map No. section 122.00 block 4 lot 16.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/06/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK UFF[]
Town of Southold � �® Appli-
cation No. lO
Judith T. Terry, -Town Clerk ` .T ci:zr � x
•Town Hall, 53095 Main Road � _ Residential
P. O. Box 1179 cr34 , : i ; Non-Residential
Southold, New York 11971 OTts' *' �
Telephone �l s [ y►� '°
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ rat Q(�
DATE "Pc-Y. q
OWNER NAME: -12-\
OWNER MAILING ADDRESS: Pa� _ I,�.\F ,,Y��
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: Le
TAX MAP NO. : Section j Block Lot ) Cp
CROSS STREET: '4e , ) 5 c \
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool \//' New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: e:::)t,,��
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.)
Signature Applicant
RECEIVED BY: •
Town Clerk's Office
DATE:
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