HomeMy WebLinkAboutBurkhardt io
11,A r. Town Hall, 53095 Main Road
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P.O. Box 1179
® ,ss22,, �� i!" Southold, New York 11971
JUDITH T.TERRY '=_� tLs ,v�� TELEPHONE
rows CLERK �`"'����/ (516)765-1801
REGISTRAR OH VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 936-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BURKHARDT, ROSE
Mailing Address 1 BOX 97
Mailing Address 2 THIRD STREET
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 THIRD STREET
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6030
Tax Map No. section 117.00 block 7 lot 15.000
Cross Street KING STREET/ORCHARD STREET
Date Of Last Pump Out 0/00/86
Issue Date: 11/29/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
v, . ,S ii-
OFFICE OF THE TOWN CLERK
Town of Southold C0f14-C'Q Application No. 4?,� 7
Judith T. Terry, Town Clerk l'I Residential
Town Hall, 53095 Main Road a kr
P. O. Box 1179 cn x :
ai; • Non-Residential
Southold, New York 11971 O '®
Telephone _o,( et
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. F34
o O
Fee $ /0
/74,/;7,
DATE
OWNER NAME: i d sL � 'f oe-vebt-
OWNER MAILING ADDRESS: th/,e I Si/2 r c-7 ‘e-x__ 7 7
/1A-et) J �� L/C NL-` //9 .5'-6.
OWNER PROPERTY ADDRESS: 71/2
burr / A✓7/ //1,,5-6.
OWNER TELEPHONE NUMBER: M. ' 7.J7 ® 6Q 3 o
TAX MAP NO. : Section 1/ 7 Block 7 Lot
CROSS STREET: 4 A/ r (- - -d. - i4(
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential L Non- esidential
DATE OF PREVIOUS PUMP-OUT: c / /nrr / e2
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 of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: // 02/ A-,V
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