HomeMy WebLinkAboutThorn, Robert ice' __'_
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ELIZABETH A. NEVILLE ,��h� G'f� Town Hall, 53095 Main Road
TOWN CLERK o= - P.O. Box 1179
REGISTRAR OF VITAL STATISTICS %+'•
Southold, New York 11971
MARRIAGE OFFICER ` �, Fax (631) 765 6145
RECORDS MANAGEMENT OFFICER `Ly'jlpl �of° Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ��
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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. 4048-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner THORN, ROBERT L
Mailing Address 1 PO BOX 373
Mailing Address 2
City St Zip SHOREHAM NY 11786-0000
Property Address 1 2560 OLD NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-821-6723
Tax Map No. section 55.00 block 2 lot 1 .001
Cross Street LIGHTHOUSE ROAD
Issue Date: 9/20/00 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK COFOC -
TOWNOFSOUfHOLD 0� CSG Application No. h
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ELIZABETH A.NEVILLE,TOWN CLERK �� $10.00 - Residential
P.O.BOX 1179
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SOUTHOLD,NEW YORK 11971 *.$ $25.00 - Non-Residential
Telephone 62 *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O. 00
DATE4,'g,-"--47,/y242vv
OWNER NAME: lUL3G27r L. y/IDi/v
OWNER MAILING ADDRESS: PO. SOX 3'23
Shoe Alt,16y. /170
OWNER PROPERTY ADDRESS: 2560 OL) Nokr[j I2,
5outi-101J))1V • 11197/
OWNER TELEPHONE NUMBER: 63) 5zi
TAX MAP NO. : Section 00 Block 2- Lot / • 00
CROSS STREET: f .G YOUA1�'S4 zV
TYPE OF SYSTEM: Septic Tank V New 1/ Existing
Cesspool ✓ New ✓ 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, to building and closest road.)
Signature of Applicant
RECEIVED BY: *l
Town Clerk's 0 e
DATE: ?/.7 9/aa
1-SUFFOLK COUNTY DEPT. HEALTH SERVICES eS
REFERENCE # RIO qq OOg1
SURVEYED 04-28-c101
CERT. ADDED 06-II-qq )4
FOUND. LOG. 12-2q-q 1
F I NAL SURVEY 08-30-2000
AMENDED Oq-14-00
SUFFOLK COUNTY TAX # ' ''j•
•
1000 - 55 - 2 - 1.1 CSp:e5
CERTIFIED TO: Po �® 0
ROBERT L. THORN �V 46 ,1� " 0
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JANE E. THORN 0�
FIRST AMERICAN TITLE �* 9)�O' 0
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