HomeMy WebLinkAboutBoergesson (2) if ff
Town Hall, 53095 Main Road
to, ei O � P.O. Box 1179
O
f Southold, New York 11971
JUDITH T.TERRY . TELEPHONE
TOWN CLERK (516) 765-1801
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. 3574-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner BOERGESSON, KEVIN AND KAREN
Mailing Address 1 P. O. BOX 855
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 322 TERRY COURT
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5756
Tax Map No. section 69.00 block 3 lot 6.003
Cross Street GLOVER STREET
Issue Date: 1/16/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICC OF THE TOWN CLERK 0cvFFDU(
s Town of Southold , � CQ Application No.35 7
Judith T. Terry, Town Clerk �► . �/
Town Hall, 53095 Main Road a $10.00 - Residential
P. 0. Box 1179 cr3h�i�;' $25.00 - Non-Residential
Southold, New York 11971 Q *.
Telephone �'ei i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- --
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
• DATE
OWNER NAME: 60ek /�e1, SOa /14V/A) ki9P8W
OWNER MAILING ADDRESS: )0- 0 • 1365( 35j
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_ _ - OWNER PROPERTY ADDRESS_ : 3 01 c2 e p o
6-
0147-140LO N `) 1I17
OWNER TELEPHONE NUMBER: 76,5 5 '756
TAX MAP NO. : Section fo 9. C O Block 3 Lot 6 •003
CROSS STREET: - et,L-c CR. Si
TYPE OF SYSTEM: • Septic Tank - .x New X Existing
Cesspool New Existing
Residential 3( Non-Residential
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 o tpplit
RECEIVED BY:
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