HomeMy WebLinkAboutKalin 1
et° t
% Nom
r $ Town Hall, 53095 Main Road
��
® `®°�t P.O. Box 1179
®� p ���� Southold, New York 11971
JUDITH T.TERRY FAX FAX(516)765-1823
TOWN CLERK
TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1498-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KALIN, ROBERT R.
Mailing Address 1 201 CHAMPLIN PLACE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 201 CHAMPLIN PLACE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0857
Tax Map No. section 34.00 block 3 lot 34.000
Cross Street ATLANTIC AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 7/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK isc _
Town of Southold � =FO(,�
`�� L Application No. /q9
Off. D
Judith T. Terry, Town ClerkY` .i► $10.00 - Residential
Town -iall, 53095 Main Road �aSF�r_ "c
u 4
P. O. Box 1179 � � i ; $25.00 - Non-Residential
Southold, New York 11971 '® O�,•'�`
Telephone of 4 ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 7; I,y J, /19
OWNER NAME: /p '� /FE i X /442-;9/ •
OWNER MAILING ADDRESS: chti /71,11;) P1,46C
PEE /VP(7/272 �i'/ i) 9W
OWNER PROPERTY- ADDRESS: j -/J /4-f
OWNER TELEPHONE NUMBER: C ' ) U 77
TAX MAP NO. : Section 3C-/ Block 3 Lot 34/
CROSS STREET: l'o,2Al r-A r) P- l''H,9m9 l_, PL 7r1 /4-71_19yiY/6/,4-YE
TYPE OF SYSTEM: Septic Tank )C New Existing X
Cesspool 2<— . New Existing S(
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 67/X9'd
LOCATION MAP: Must be attached hereto efore permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
d
Signature of Applicant
RECEIVED BY: ci
Fown Clerk's Office
DATE: 7/2.-d/f
•
,
, I
,
• _ - -- _ - ,_ _ __ ___ _ _ _ til _ _ _ _ ,____ _ _..-_ _-__ _ _ .
I I
14 I
e -
r ,
. ;
o
�� ��
>
r -
, ;
QT1 4
•
sc-PTiE
f •A3���/?T' �, �3� �,
, Tangy r� = /
'o / C Yk1/�JN /I. = pie t- ,
' L
- r