HomeMy WebLinkAboutBoergesson (3) JUDITH T. TERRY -��/��' Town Hall, 5
ti y� 3095 Main Road
TOWN CLERK = P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS - - Southold, New York 11971
MARRIAGE OFFICER _„_
• Fax (516)765-1823
• ,; % Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1607-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOERGESSON, ROBERT & JOHANNA
Mailing Address 1 670 SEAWOOD DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 670 SEAWOOD DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2092
Tax Map No. section 78.00 block 8 lot 11 .000
Cross Street NORTH BAYVIEW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFIC 'OF THE TOWN CLERK
Town of Southold � LOG= Application No. /Z-C:52
Judith T. Terry, Town Clerk . ,` 4 y:� -
Town Hall, 53095 Main Road ..;4 ^` $10.00 Residential
P. 0. Box 1179 cn = ` xr ; $25.00 - Non-Residential
Southold, New York 1197104_O 0�,��
Telephone 91 * `��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /c/ 'z 3
'OWNER NAME -6c,{, 7Joko "r4 .J A(-. 12_,C; 0-'L •
OWNER MAILING ADDRESS: ,jo SLSz 0 0)?
„:,•D -' � 2 /J-1 1 1 7 /
OWNER PROPERTY ADDRESS: jl--r- f O V
OWNER TELEPHONE NUMBER: 5 -- 74, ;= Zo9 `z—
TAX MAP NO. : Section Block c7 Lot / -/
CROSS STREET: /Uo,g vL 2d .'
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool �( New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: T/c0
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
J _
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