HomeMy WebLinkAboutBurns (4) soil OFFO` C-
JUDITH T.TERRY �� '
�� Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
,�` Southold,New York 11971
REGISTRAR OF VITAL STATISTICS :1.4�� �,�1 Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER -4 � �iil Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,.°g°
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3626-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BURNS, MARGERY D.
Mailing Address 1 P. O. BOX 566
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-7640
Tax Map No. section 61 .00 block 1 lot 8.001
Cross Street HORTON'S LANE
Issue Date: 5/06/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFACE OF THE TOWN CLERK ?
Town of Southold , c CQG Application No,c 662,
Judith T. Terry, Town Clerk . Z r, - 0.41
Town Hall, 53095 Main Road -4 $10.00 - Residential
P. O. Box 1179 «, ��" $25.00 - Non-Residential
Southold, New York 11971 O *.$
Telephone -O.( * 1% •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ '
DATE 4- /- q7
OWNER NAME: L{R/k--� 14 ifk -a Cr' c .
OWNER MAILING ADDRESS:
0c- iJ - ' 1/4t
OWNER PROPERTY ADDRESS: JAW (?c/, - -
Oc)7 NL ((q11
OWNER TELEPHONE NUMBER: 3 ) ( , 16 ( ,6 (c7 _
TAX MAP NO. : Section 06 ( Block 0 t Lot OS. I-
CROSS,STREET: eO` t )Zt-A. ,G
TYPE OF SYSTEM: ''Septic.Tank 17 New Existing
bi,) `dLl Cesspool " New Existing
Z' Residential 4✓ Non-Residential
1
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.)
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RECEIVED BY: c
c. � _
/ N 's Office
DATE: . ,
MAY :5 1997
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Southold To]..n Clerk
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