HomeMy WebLinkAboutBenken 40. 4EILli
A!' �' �4*-JUDITH T. TERRY '� � �;� Town Hall, 53095 Main Road
TOWN CLERK \� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS o Southold, New York 11971
MARRIAGE OFFICER � Fax (516) 765-1823
�® 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. 1927-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BENKEN, JOAN
Mailing Address 1 250 HOBART ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 250 HOBART ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5619
Tax Map No. section 62.00 block 3 lot 5.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FFO
Town of Southold %�.a- . 7 '
•,��� �ti (XI' , Application No.(
Judith T. Terry, Town Clerk k �& . %) $10.00 - Residential
• Town Hall, 53095 Main Road a y x =,
p. O. Box 1179 �V,:,Rf`~ hi ` $25.00 - Non-Residential
Southold, New York 11971 O ® - fat r ' 'J��
Telephone 'fiOj ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE b (IS c'l -2—
Bel01/42 OWNER NAME: j (''C� (J
OWNER MAILING ADDRESS: ,_PD )4o b 3 V f k d
cc,bokh . d. fr, tit q ) 7
OWNER PROPERTY ADDRESS: s tl V)nF-'
OWNER TELEPHONE NUMBER:: IQS -S
TAX MAP NO. : Section ( 0__ Block Lot
CROSS STREET: at uk-) -)\00- (�
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.)
r,i � \ � � �
Signature of ' pplicant
RECEIVED BY: ` ( Q�� - - - -
To n Clerk's Office
RECOVER
DATE:
JUN 171992
town Clerk SOW
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