HomeMy WebLinkAboutBascomb OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk r � ` i►
Town Hall, 53095 Main Road
P. O. Box 1179 to "
Southold, New York 11971 '4 T's .$
Telephone .� •00
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 58 Residential XX
Non-Residential
Fee $ 10.00
Septic Cesspool XX
NAME OF OWNER: Roy and Evelyn Bascomb
OWNER MAILING ADDRESS: 360 Westview Drive
Mattituck, New York 11952
OWNER -PROPERTY -ADDRESS: --360---Westview--Drive - -
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-8661
TAX MAP NO. : Section 139 Block 1 Lot 12
CROSS STREET: Brower Road and Mayflower Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XX, New Existing XX
Residential XX Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1976
Judith T. Terr
Southold Town Clerk
DATE: September 22, 1986 -
(TOWN SEAL)
OFFICE OF THE TOWN CLERK f If OU. =
Town of Southold �� .rte C'�G', Application No.
Judith T. Terry, Town Clerk ?.} i► `y
�x s•C�, Residential )�
Town Hall, 53095 Main Road a-.;
P. O. Box 1179 cnTA?rT► ; Non-Residential
Southold, New York 11971 Q ® A
Telephone .( Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /( i:
DATE -420i
� � trAi
OWNER NAME: ® � eif Vi t 1
OWNER MAILING ADDRESS: 3&OQ�G�lV/
OWNER PROPERTY ADDRESS: 3,4731 /E 4-i 4 ' 1/,
OWNER TELEPHONE NUMBER: 37 6. f/! f"/
TAX MAP NO. : Section /39 Block / Lot
CROSS STREET: 14)-STil/ cd h • I o th- �-�. ) 1 '14yia-70)410-/
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /97C
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.)
Y Signature of Applican
6'7;
RECEIVED BY:
Town Clerk's Office
DATE:
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