HomeMy WebLinkAboutChristensen 114114 VULit9&
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c W$ Town Hall, 53095 Main Road
00 ®C-���1 P.O. Box 1179
___40 iii `volo. Southold, New York 11971
JUDITH T.TERRY :, ,iii#' 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. 1554-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CHRISTENSEN, ROBERT L.
Mailing Address 1 100 DEVOE ROAD
Mailing Address 2
City St Zip CHAPPAQUA NY 10514-0000
Property Address 1 WEST CREEK AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 914-238-8571
Tax Map No. section 110.00 block 2 lot 7.000
Cross Street MIDWOOD ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK gc.\FFO(,r�'-
Town of Southold � CO � Application No. 4G"-(
Judith T. Terry, Town Clerk . A;;;-.‘
Town Hall, 53095 Main Road g -� $10.00 - Residential
P. O. Box 1179 cn .r ,.<,: ; $25.00 - Non-Residential
Southold, New York 11971 O 'Aft'
, �J
Telephone � '/
(516) 765-1801 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /c�
DATEf. ‘gf! ,el„01 0-
'OWNER NAME: gpOgg-1 L C1 -TE1NJSAJ .
OWNER MAILING ADDRESS: )pv 2 -vim
-M1 12 L?$ l N'/ 1 ta`6-7Y
OWNER PROPERTY ADDRESS:
e. tumor -7 , 'I> 9 7�
OWNER TELEPHONE NUMBERECP9)2. $—E, !tea (6V; 3y--44r-17
TAX MAP NO. : Section /PO Block Lot 7
CROSS STREET: IA/ 11-'m $1-L
TYPE ,OF SYSTEM: Septic Tank - New Existing
Cesspool New Existing
Residential r/. Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
.fir 414
falL...-AA 1414 Pre 4Ak.f•-, -
Signat-re of App icant
RECEIVED� BY: •_ - -
Town Clerk's Office
DATE: •
/IL, 1 tio— 2,,--. 7
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