HomeMy WebLinkAboutFohrkolb, Andrew T. ,� ////,01)?° FO(�co
ELIZABETH A. NEVILLE '�1 h� * \ Town Hall, 53095 Main Road
TOWN CLERK o * I, P.O. Box 1179
col
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
,
MARRIAGE OFFICER t% Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER `�y_'Jlpl Alg �a��//� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ���/� southoldtown.northfork.net
.....•�0
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4188-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner FOHRKOLB, ANDREW C.
Mailing Address 1 670 HOLDEN AVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 ALVAH'S LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 631-734-6779
Tax Map No. section 102.00 block 4 lot 5.005
Cross Street BRIDLE LANE
61424422?ehdlo
Issue Date: 2/04/03 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
M .• ••
•
OFFICE OF THE TOWN CLERK �F �C
FQ
TOWN OFSOUTHOLD o��5 . OIj Application No. c
ELIZABETH A.NEVILLE,TOWN CLERK � $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 �� $25.00 - Non-Residential
Telephone 701 ••••
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10.00
DATE 1/30/03
OWNER NAME: ANDREW C FOHRKOLB
OWNER MAILING ADDRESS: 670 HOLDEN AVE
CUTCHOGUE, NY 11935
OWNER PROPERTY ADDRESS: ALVAH'S T.ANE
(`TrFCHnarw.., NY 11935
OWNER TELEPHONE NUMBER: 734 6779
TAX MAP NO. : Section 102.00 Block 4 Lot 5.005
CROSS STREET: BRIDLE saw 1-f+
TYPE OF SYSTEM: Septic Tank x New Existing
Cesspool X New Existing
Residential g 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.)
4fri
Sig 'at "re : App icant
RECEIVED BY: (/(1XM
Town
Clerk's Office
DATE: / / 3//d3