HomeMy WebLinkAboutAckermann OFFICE OF THE TOWN CLERKF� C�
Town of Southold ��� � �j -
Judith T. Terry, Town Clerk � 4�-
g
Town Hall, 53095 Main Road f ,
P. 0. Box 1179 � � :
Southold, New York 11971Q,,yy��®,. �
Telephone jt
(516) 765-1801 `
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 190 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Barbara B. Ackermann
OWNER MAILING ADDRESS: Box 330
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: Azalea Road, Mattituck;Estates
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-5868
TAX MAP NO. : Section 115 Block 6 Lot 9
CROSS STREET: Cardinal Drive
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Terry
Southold Town Clerk
DATE: January 6, 1987
I 1
(TOWN SEAL)
„
OFFICE OF THE TOWN CLERK CgF U( -
Town of Southold CQ ' Application No*/ b
Judith T. Terry, Town Clerk �` `_` pp
Town Hall, 53095 Main Road .�� Residential
P. 0. Box 1179 to Z' _ Non-Residential
Southold, New York 11971 �o.'
O
Telephone .( * Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
/Fee $ a Ge
•
DATE S
OWNER NAME:
OWNER MAILING ADDRESS: 3 3 0
OWNER PROPERTY ADDRESS: 67--2- .- �eQ� 7' �-A Ee s •
rvy c(q
OWNER TELEPHONE NUMBER: SCe Q.3 1/45—E 67-Y
TAX MAP NO. : Section //5-- Block , Lot 9'
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 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.) •
fi
Signature of Applicant
RECEIVED BY: ( a c- 1-
Town CI k's Offi e
DATE: I a�/ / ' �6P'
( v /
_ _
(W�
"' \
0 '
1
r�Z
. _
s-C
I\JJ �� I
.S '