HomeMy WebLinkAboutSchooff, Rolf ` ////O;OSu`fO��AO
ELIZABETH A.NEVILLE �� �� Gy � Town Hall, 53095 Main Road
TOWN CLERKti P.O. Box 1179
Southold, New York 11971
REGISTRAR.OF VITAL STATISTICS
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER `�y_41I) jig �a� i ' 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. 4221-R Residential x Non-Residential
Fee $ 10.00 New Existing X
Name of Owner SCHOOFF, ROLF C.
Mailing Address 1 11 AUBURN DRIVE
mailing Address 2
City St Zip GREENLAWN NY 11740-0000
Property Address 1 1780 FOUNDERS PATH
Property Address 2
City St zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-427-7225
Tax Map No. section 64.00 block 4 lot 12.002
Cross Street OLD SHIPYARD LANE
Issue Date: 10/09/03 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ��0 4‘ Town Hall, 53095 Main Road
TOWN CLERK �� p P.O. Box 1179
y Z $ Southold,
New York 11971
REGISTRAR OF VITAL STATISTICS ' v t
MARRIAGE OFFICER 'F 1� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER - *4 ��/ Fax
(631) 765-1800
FREEDOM OF INFORMATION OFFICER =�'�I , -14,,.'l southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $101/or Non-Residential @ $25 Application No.
Permit No. )3 0 $ R K
Owner Name ()G ( C ' acH00c-- r
liOwner Mailing Address ,4() 3(JRA D(2
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G ivIv/J , ply 117 O
Owner Property Address /7'x') FOU/01W. '
$O1dOa , NY ( ( ?7/
Owner Telephone No. (631/) a7°
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Tax Map No: Section 6 It Q°Block 41 Lot _.),2 00 .
Cross Street Oe-P Sf9lf'X9// b 4,9 XJ
Please check each that applies: New Construction
Alteration to Existipg System
Residential V 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.)
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Signature rf Applicant / Date
Received by:
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