HomeMy WebLinkAboutBerg OFFICE OF THE TOWN CLERK •C0FOCkcol�
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179
Southold, New York 11971 ..,„sob . ® �` ��.`;0� •�
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• Telephone = 4i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 254 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Paul M. Berg and Nellie J. Berg
OWNER MAILING ADDRESS: P.O. Box 126
Peconic, New YOrk 11958
OWNER PROPERTY ADDRESS: Wells Road
Peconic, New York
• OWNER TELEPHONE NUMBER: 516-765-1695
TAX MAP NO. : Section 86 Block 2 Lot 3
CROSS STREET: Route 25
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
• Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: April 5, 1985
Judith T. Terr
- Southold Town Clerk
DATE: April 7,. 1987 - -
•
!• (TOWN SEAL)
OFFICE OF THE TOWN CLERK c3\WFQ�L'
Town of Southold Q Application No. S_
Off. OG
Judith T. Terry, Town Clerk ,� -�
Town Hall 53095 Main Road '� ''" Residential
P. O. Box 1179 cnt Non-Residential
Southold, New York 11971
Telephone ®,( /%4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.c?
Fee $
DATE 3 / /'iia' 2 ' j rer—
OWNER NAME: 6) /j, D,v . 13e)240 lei./. S R,Gt.,
OWNER MAILING ADDRESS: ® g
OWNER PROPERTY ADDRESS:
JJ /6TOWNER TELEPHONE NUMBER: 71, 6---- 169-6--
TAX
AX MAP NO. : Section �6 Block Lot 3
CROSS STREET: ep„,� �
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool jx 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.)
C� l
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Signature of Applirnt
RECEIVED BY:
Town Clerk's Office
DATE:
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