HomeMy WebLinkAboutBardes r �
JUDITH T. TERRY ` , Town Hall, 53095 Main Road
TOWN CLERK vwa � P.O. Box 1179
REGISTRAR OF VITAL STATISTICS , ,� Southold, New York 11971
MARRIAGE OFFICER
c� �, �!' Fax (516) 765-1823
�® �l Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1986-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BARDES, ELIZABETH
Mailing Address 1 6133 VALINDA AVENUE
Mailing Address 2
City St Zip ALTA LOMA CA 91701-0000
Property Address 1 THREE WATERS LANE
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3885
Tax Map No. section 15.00 block 6 lot 25.000
Cross Street MAIN ROAD
Date Of Last Pump Out 11/00/91
Issue Date: 10/15/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COFOZ =
Town of Southold � C�G� Application No. )
Judith T. Terry, Town Clerk x k:
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Town Hall, 53095 Main Road -� $10.00 - Residential ✓i,
P. O. Box 1179 cni �`'" $25.00 - Non-Residential
Southold, New York 11971 O ` {O�,•'`�
Telephone N� `
° (516) 765-1801 ,
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for'
OPERATION PERMIT-
SEPTIC TANK or CESSPOOL •
Operation Permit No. j q2
Fee $L / 0 : 6
DATE1l 1I'O,
OWNER NAME-: j/ 1 r� j H g ig,04s
OWNER MAILING ADDRESS: GS.33 VALis1OR Prjj
A LIR LOMA CuAFoemPk 94901
OWNER PROPERTY ADDRESS:C-- - ift � ` �
OWNER TELEPHONE NUMBER: 56 Vic . �Q4j
TAX MAP NO. : Section /6 Block G Lot ;ZS'
_ CROSS STREET: �(�: ,
TYPE OF SYSTEM:_,`-Septic.Tank-- X -- New Existing • X • -
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: _ 1/ is i I
LOCATION MAP: Must be attached hereto before permit" maybe issued. '
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
(LIZ (6,i-ANO ic2k)
Signature o App scant-
RECEIVED BY: %/ ,
• . .. . . .w Cle 's Office
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DATE: 16 ILS. . - -.-'
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