HomeMy WebLinkAboutMartz, Theodore Jr (2) ,,,,,iii,,,,,
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ELIZABETH A.NEVII,LE ,� h y�;•
Town Hall,53095 Main Road
TOWN CLERK P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS ,',i Southold,New York 11971
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER y'�pl �a0) Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER ,,,'I southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4257-R Residential x Non-Residential
Fee $ 10.00 New X Existing
Name of owner MARTZ, JR THEODORE C
Mailing Address 1 145 RYERSON AVENUE
Mailing Address 2
City St Zip MANORVILLE NY 11949-0000
Property Address 1 1200 BRAY AVENUE
Property Address 2
City St Zip LAUREL NY 11948-0000
owner Telephone No. 631-878-8443
Tax Map No. section 126.00 block 7 lot 31.000
Cross Street 6TH STREET
Issue Date: 8/06/04 Elizabeth A. Neville
southold Town clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE `
,'i% Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold,New York 11971
MARRIAGE OFFICER .104OV
` ��� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER ' , � 'O.
Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER '_`�[ �,►�` southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 X or Non-Residential @ $25 Application No.
Permit No. (-La
'Ih odore C. M3rtz Jr.
Owner Name
Owner Mailing Address 145 Ryerson Avenuae
Marorville, NY 11949
Owner Property Address 1200 Bray AvEntE
Laurel, NY
Owner Telephone No. (631)-878-8443
Tax Map No: Section 126 Bloch 07 Lot 031
6th Street
Cross Street
Please check each that applies: New Construction x
Alteration to Existing System
Residential X Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet fr• em to building
and closest road. New construction may submit copy ey . ' - i.5 . •pro al.)
401,
Signature of Applican, Date
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Received by: ,� ,