HomeMy WebLinkAboutKeleman, Stephen ,�O,�O� S11FF0(�-�0. .
MainELIZABETH A.NEVILLE
1141# Gy Town Hall, 53095 Road
TOWN CLERK o P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ".°O44_ Southold,New York 11971
47$ Fax(631) 765-6145
MARRIAGE OFFICER `. �1
RECORDS MANAGEMENT OFFICER ___ Q! r/�� 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. 4222-R Residential x Non-Residential
Fee $ 10.00 New Existing X
Name of Owner KELEMEN, STEPHEN
Mailing Address 1 P 0 BOX 575
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 38675 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 631-323-3574
Tax Map No. section 15.00 block 2 lot 17.004
cross Street RYDER FARM LANE
Issue Date: 10/09/03 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
. IS° i ZZ
OFFICE OF THE TOWN CLERK
�S�FFO(,�
TOWN OFSOUTHOLD ` ��, CSG Application No.
ELIZABETH A.NEVILLE,TOWN CLERK
�C � $10. - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 cn Z' .00 - Non-Residential
Telephone . ?/ Jilt N6) .•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
RECEMD 0-
-._
for
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SEP 2 3 20e?
OPERATION PERMIT
SEPTIC TANK or CESSPOOL Southold Tom,Clerk
Operation Permit No.
Fee $
/ . /,/
DATE
OWNER NAME: eA-0
ST--- I .....- 4' ..... (.. •
OWNER MAILING ADDRS: O .0110
OWNER PROPERTY ADDRESS:___ Ai LIVE " A.„,,r,i_maiiiram. *A .0
OWNER TELEPHONE NUMBER: y
TAX MAP NO. : Section / 5' Block Lot f/ 7s V
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Li Existing
Residential 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, buil.' g nd closest road.)
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Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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Stephen Kelemen
77 Main Road
Orient