HomeMy WebLinkAboutBoursiquot OFE4i10E JF THE TOWN CLERK ' cOFQC�'{�.'
Town of Southold 0, ',`
Judith T. Terry, Town Clerk % LZ fa
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Town Hall, 53095 Main Road h ir, ,,.,
P. 0. Box 1179 ccr3am `" x
Southold, New York 11971
Telephone �l I`
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 573 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Barbara and Ange Boursiquot
OWNER MAILING ADDRESS: 100 Beekman Street, Apt. 12C
New York, New York 10038
OWNER PROPERTY ADDRESS: Main Road
Mattituck, New York
OWNER TELEPHONE NUMBER: 212-571-0484
TAX MAP NO. : Section 122 Block 6 Lot 15
CROSS STREET: Factory Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
egeaVe."4:"erw".•
Judith T. T ry
Southold Town Clerk
DATE: January 11 , 1988
(TOWN SEAL)
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OFICg OF THE TOWN CLERK - ,�FFO(r„=
Town of Southold ®�� Y. �»�. ®G�_, Application No.
Judith T. Terry, Town Clerk � KIT •
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Town Hall, 53095 Main Road ® - `i Residential
P. O. Box 1179 Non-Residential
Southold, New York 11971 ® ® •'•1
Telephone •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ Ocb
DATE 191 Oa (fq-
OW N ER NAME: ,.belr + 14 ocie g let(®V
OWNER MAILING ADDRESS: 1 OO Bim• rn u) 5, -2€4-- T h U
N C", i003-e
OWNER PROPERTY ADDRESS: gain RtIeLA ke—VA-thj
OWNER TELEPHONE NUMBER: 9.1a -7-I v T �'cl
TAX MAP NO. : Section i ad, Block 6 Lot da
CROSS STREET: "
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ‘/ New Existing —
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: la/4)1��
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 Applica
RECEIVED BY: uyJ
RECElvEbown arkqeWificLe
DATE: JAN 1987
T^�"�� C!rk Southold
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