HomeMy WebLinkAboutJaswal, Saroj � O
ELIZABETH A.NEVILLE ,�� Town Hall, 53095 Main Road
TOWN CLERK 1 o P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
I, Fax(631) 765-6145
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER `�y�Ql ���i��' Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ���� southoldtown.northfork.net
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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. 4220-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner JASWAL, SAROJ
mailing Address 1 22 NICOLE CT
mailing Address 2
City St Zip BOHEMIA NY 11716-0000
Property Address 1 35900 ROUTE 48
Property Address 2
City St zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-567-3424
Tax Map No. section 69.00 block 4 lot 5.000
Cross Street CAROLE RD
Issue Date: 10/01/03 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
ii OFFoc,��
ELIZABETH A.NEVILLE 114�`t`to°� Town Hall, 53095 Main Road
TOWN CLERK § ; P.O.Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS v. Al
MARRIAGE OFFICER : � Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = 0 ��� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER --_ * ,�a��i southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
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Resident al @ $10 or Non Residential @ $25 Application No.
Permit No. `30 6 0.0 R._
Owner Name SR • -0 4 kI A
Owner Mailing Address 2 2. N i co11-A- 160#-6-1-0 6
Owner Property Address 3 3 7 v O 1\-k‘ IQZ 4%
E ca017-1-o Lo lc/
Owner Telephone No. 411- 5-6 R-
Tax Map No: Section 6 9 Block "I Lot T O C�
Cross Street c,Pt. 1 L e-
Please check each that applies: New Construction
Alteration to Existing System
Residential L— 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.)
Signature of Applicant Date
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