HomeMy WebLinkAboutBurgon ��,4'c '''JUt
* Town Hall, 53095 Main Road
�® . �$1 P.O. Box 1179
®1 �®��� Southold, New York 11971
JUDITH T.TERRY v46 iP TELEPHONE
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TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF 5OUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 648-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner BURGON, AURELIA
Mailing Address 1 P. O. BOX 679
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000 -
Owner Telephone No. 516-298-8486
Tax Map No. section 142. 00 block 2 lot 18.000
Cross Street PACIFIC STREET
Date Of Last Pump Out 0/00/00
17/ ,
Issue Date: 3/09/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •ice
OFFICE OF THE TOWN CLERK,- •SFO(,r
Town of Southold CQ ' Application No. 41/
Judith T. Terry, Town Clerk � '
Town Hall, 53095 Main Road P52 Residential
cn -.4
P. O. Box 1179 ����: �z Non-Residential
Southold, New York 11971 O , •kr
Telephone O,(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /U—
DATEAzi !gr/
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OWNER NAME: Lt
OWNER MAILING ADDRESS: 1L�. 4: 0 X C l y
`.27 a 4 edg v-)./
OWNER PROPERTY ADDRESS: Q,
yOWNER TELEPHONE NUMBER: ,,27-,--„Ffra
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM_: Septic Tank New Existing
Cesspool New Existing i✓"
Residential I/ Non-Residential
- DATE OF PREVIOUS PUMP-OUT: 122, /911
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.)
ae7c-eYx_,AL
Signature of App ant
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RECEIVED BY: kd_ ��
Town (Clerk's ffice
- DATE: 3/9/1K / — —/a
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/27/-1-/A) demi)