HomeMy WebLinkAboutAlbertson (3) cti);JUDITH T. TERRY : "kms Town Hall, 53095 Main Road
TOWN CLERK ® ' P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ( r ,,� Southold, New York 11971
MARRIAGE OFFICER
e ' - �'°' ," Fax (516) 765-1823
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® 1.• Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1579-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ALBERTSON, STEPHEN, SHERYL-LEE
Mailing Address 1 P. O. BOX 1268
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 53557 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2689
Tax Map No. section 61 .00 block 4 lot -97008f 9,-
Cross
,Cross Street WELLS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 11/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
M t
OFFICE OF THE TOWN CLERK •c�IFD(,rC'"
Town of Southold �Q Application No. 15 7/
Judith T. Terry, Town Clerk . ' ;;; y
Town Hall, 53095 Main Road = $10.00 - Residential
P. O. Box 1179 crn
>. - $25.00 - Non-Residential
Southold, New York 11971
Telephone =0j *NV,0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE // in
'OWNER NAME: ` hey, + ( herri/-Leer 4/b p_76.-,0,0
OWNER MAILING ADDRESS: /PO.jjy6 /a6 g
OWNER PROPERTY ADDRESS: 0---(363--17/1-116-1:-/L
P97/97/
•
OWNER TELEPHONE NUMBER: v---/e„ _ 765----06, 8' 7
TAX MAP NO. : Section 66./ Block rLot /o(
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential \‘(' Non-Residential
DATE OF PREVIOUS PUMP-OUT: -- 6190
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.)
3,...kede, a1.6_,„Thon
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: