HomeMy WebLinkAboutAlbertson (2) V
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'c=1 Fri ' Town Hall, 53095 Main Road
;V�� ®�- P.O. Box 1179
®1 41 ��o' Southold, New York 11971
JUDITH T.TERRY ...., ,,,,i' TELEFAX PHONE)765-1823 1801
TOWN CLERK
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. 1566-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ALBERTSON, LESTER M.
Mailing Address 1 56125 MAIN STREET
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 56125 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3824
Tax Map No. section 63.00 block 3 lot 10.000
Cross Street BOISSEAU AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cIFOUr
Town of Southold �� CG� Application No.
Judith T. Terry, Town Clerk . ;.}f` 3• y
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Town Hall, 53095 Main Road a �;-� � � . I $10.00 - Residential
P. 0. Box 1179 cn �' `= « ` $25.00 - Non-Residential
Southold, New York 11971 •�'�® .Oyu$
Telephone Q( -01
(516) 765-1801
TOWN OF SOUTHOLD •
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: O� QS Y -Zeba-" vhai-is •
•
OWNER MAILING ADDRESS: CF/>� -27-2 eg ® 15 5
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OWNER PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: c_4'7‘ 8-)--
TAX MAP NO. : Section Block Lot
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.)
41101P
Signa re of Applicant
RECEIVED BY:
-Town Clerk's Office
DATE:
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