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ELIZABETH A.NEVILLE � y� Town Hall, 53095 Main Road
TOWN CLERK y P.O.Box 1179 ;.
REGISTRAR OF VITAL STATISTICS r Southold,New York 11971
MARRIAGE OFFICER 1i �� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER "'/Ql �a� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4240-R Residential X Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner KOEHLER SR, RUDOLPH_
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Mailing Address 1 PO Box 1714
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Mailing Address 2
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City St zip SOUTHOLD NY 11971-0000
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Property Address 1 4265 NORTH BAYVI ROAD
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Property Address 2 --------------------
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City St zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 631-765-3488 _
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Tax Map No. section 79.00 bloc -3 lot 13.000
Cross Street
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Issue Date: 1/28/04 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE 1OGy� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
co Z Southold,New York 11971
REGISTRAR.OF VITAL STATISTICS v�
• MARRIAGE OFFICER Oy Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �JJ O Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER O'� �� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 /or Non-Residential @$25 Application No.
4z4
Permit No. 3 017 7
Owner Name RL)VN_P4 (RmAyloalt
Owner Mailing Address P.d- 00K 1-7 q-
s6U t-M C>L .1P . (L a-
Owner Property Address 4-Z.6 s 1�f-14- 8A-7-( d� PO)"
a•
Owner Telephone No. 34 8 S
+73 SSS
Tax Map No: Section ��•� Block �S Lot 1
Cross Street
Please check each that applies: New Construction p /
Alteration to Existing System
Residential �/° Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
a4.,. a---v T (2. 1 a d�-
Signature of Qplicant Date
Received by:
Town Of Southold
P.O Box 1179
Y Southold, NY 11971
* * * RECEIPT * * *
Date: 01/14/04 Receipt#: 0
Transaction(s): Subtotal
1 Septic Permit- Operation - Resid. $10.00
Cash Total Paid: $10.00
Name: Koehler, Rudolph
4265 North Bayview Road
Southold, NY 11971
Clerk ID: LYNDAB Internal ID:87485