HomeMy WebLinkAboutGeorge, Stephen 01'\, COG
ELIZABETH A.NEVILLE ,��� y ; Town Hall,53095 Main Road
TOWN CLERK %) O P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS rry
Southold,New York 11971
MARRIAGE OFFICER �r 1S���, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER :_�Ql �a0�i. Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER ,�'� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4267-R Residential X Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner STEPHEN GEORGE
Mailing Address 1 154-52 24TH AVENUE
Mailing Address 2
City St Zip WHITESTONE NY 11357-0000
Property Address 1 ADAM'S ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 718-939-0516
Tax Map No. section 113.00 block 12 lot 9.000
Cross Street COX NECK ROAD
Issue Date: 9/28/04 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE A ,``1` Gy`; Town Hall, 53095 Main Road
TOWN CLERK 1 g ; P.O. Box 1179
I h Z $ Southold, New York 11971
REGISTRAR OF VITAL STATISTICS .s. Ri t
MARRIAGE OFFICER % G 'F 1� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER
,'y Q`'��� Fax
(631) 765-1800
FREEDOM OF INFORMATION OFFICER ---
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 or Non-Residential @ $25 Application No. IfX-)
Permit No.
Owner Name Stephen George
Owner Mailing Address 154-52 24th Ave.
Whitestone, New York 11357
Owner Property Address Adam's Road
Mattituck, New York 11952
Owner Telephone No. (718) 939-0516
Tax Map No: Section 113.00 Block 12 _ Lot 9.000
Cross Street Cox Neck Road
Please check each that applies: New Construction xx
Alteration to Existing System
Residential xx Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
301fmr-d-' ce7 ,
'gna e of Applica_.,5',:- ,-..-
nt Date
Received by: out_i
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