HomeMy WebLinkAboutBerner 40.91015,
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��. Town Hall, 53095 Main Road,
kVe ���;1 P.O. Box 1179
®� 001,/'' Southold, New York 11971
JUDITH T.TERRY =-%.,,,zip%'`11I FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1314-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BERNER, PAUL E.
Mailing Address 1 180 NAVY STREET
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 180 NAVY STREET
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2603
Tax Map No. section 26.00 block 1 lot 24.000
Cross Street VILLAGE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 11/21/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .c3IFO(,��'-
Town of Southold �� {. CSG Application No./3 /(/
Judith T. Terry, Town Clerk . . - �•y
Town Hall, 53095 Main Road °� -< $10.00 - Residential
P. O. Box 1179 `` ' .
$25.00 - Non-Residential
Southold, New York 11971 O ® ��`�
Telephone _®j ��� •'
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
v,
Fee $ /9
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OWNER NAME: ��� • �C E /(3 - - fir
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OWNER MAILING ADDRESS: /g / V 7 f�
_..- _.�_OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 3 2- 3 2-6 03
TAX MAP NO. : Section Block / Lot 2
CROSS STREET: ( ea e a"rr e/ g74,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential X Non-Residential ,
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DATE OF PREVIOUS PUMP-OUT: ' O - `�P '/ /94)
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.)
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�/ // -/ Signature of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE: