HomeMy WebLinkAboutBokina JUDITH T. TERRY ,'/®® 14,®�
�^ Town Hall, 53095 Main Road
TO CLERK � '" P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS Z, ® Southold, New York 11971
MARRIAGE OFFICER +d � Fax (516) 765-1823
;g �'*�' 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. 1719-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOKINA, MARGARET AND JOSEPH
Mailing Address 1 7850 BRIDGE LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 7850 BRIDGE LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6027
Tax Map No. section 84.00 block 1 lot 5.000
Cross Street ROUNTE 48 & OREGON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/02/91 Judith T. Terry
Southold Town Clerk
•
(TOWN SEAL)
II-OFFICE OF THE TOWN CLERK '-
Town of Southold 0 �CQ Application No. 001
Judith T. Terry, Town Clerk
$%-* .G 7 $10.00 - Residential
Town Hall, 53095 Main Road
P. 0. Box 1179 v' z % ; $25.00 - Non-Residential
Southold, New York 11971 4161-144-. � "•
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Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
cm
OWNER NAME: PIP I -! • -lib A &-akIIPP
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OWNER MAILING ADDRESS: 7F--6-61 r, — La
OWNER PROPERTY ADDRESS :_ c-o- a h p' CI9 e_, '21
OWNER TELEPHONE NUMBER: 3 / ,_ 73`77
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TAX MAP NO. : Section ? (O 0 Block (1/ Lot
CROSS STREET: �tA -I
67/e• � 0� 0 n [6'7d-
TYPE
6�L
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool New Existing os.- " - /6
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.)
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Sigiature of -,. . icant
RECEIVED BY:
Town Clerk's Office
DATE:
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