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HomeMy WebLinkAboutJacobs, Stephen ,$UFfOu►0 ELIZABETH A. NEVILLE _ *j� Town Hall, 53095 Main Road TOWN CLERK o - Z P.O. Box 1179 REGISTRAR OF VITAL STATISTICS '�� Southold, New York 11971 MARRIAGE OFFICER Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ;*Ol 1.11 Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER r,i OFFICE OF THE TOWN CLERK SOUTHOLD 112WIRENIA9MIRTIMIBIDSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL 040 Operation Permit No. 40770-R Residential X Non-Residential Fee $ 10.00 New X Existing Name Of Owner JACOBS, STEPHEN Mailing Address 1 MEADOW BEACH LANE Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 MEADOW BEACH LANE Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 631-734-7181 Tax Map No. section 115.00 block 170 lot 17.002 Cross Street NEW SUFFOLK AVENUE jefiebiatita Issue Date: 4/12/01 Elizabeth A. Neville Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK 17 TOWN OF SOUTHOLD �, CDi► Application No. /' 7 J 1 ABETH A.NEVILLE,TOWN CLERK -$10.00 Residential P.O.BOX 1179 SOUCHOLD,NEWYORK 11971 0 'W$ $25.00 - Non-Residential Telephone *0414 01 (516) 765-1801i TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERAT ION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ /0,Z0 DATE 1 V /o I Zool OWNER NAME: PrCo551 S' G ► 1 3rd OWNER MAILING ADDRESS: frie79b©,d 6-qcr,► rrii-r c:X- 1`)."2I t't OWNER PROPERTY ADDRESS: tr)e7lbcosAi R, Cr3 i_ )-p%/ l)n-T-rolfri Cg. NY OWNER TELEPHONE NUMBER: 73q- 718/ TAX MAP NO. : Section J J 5 Block fl Lot CROSS STREET: NeW 514FFv 1,lc prverile TYPE OF SYSTEM: Septic Tank New 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.) r w a y v Signature of Applicant RECEIVED BY: `'V A2-14(-1 ---e-____ Town Clerk's Office DATE: Y/' �/�