HomeMy WebLinkAboutGoldman, Sarah (3) dil S FFOL,r►
ELIZABETH A.NEVILLE �� �` Town Hall, 53095 Main Road
TOWN CLERK ei� _ ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O �� Southold, New York 11971
MARRIAGE OFFICER V 4if, 4 ' Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER : ' * `�► '�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. 4269-R Residential X Non-Residential
Fee $ 10.00 New x Existing
Name Of Owner GOLDMAN, SARAH
Mailing Address 1 PO BOX 626
mailing Address 2
City St zip NEW SUFFOLK NY 11956-0000
Property Address 1 480 FRED STREET
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
owner Telephone No. 631-734-5847
Tax Map No. section 117.00 block 4 lot 19.000
Cross Street GEORGE ROAD
Issue Date: 10/14/04 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE Ci 0€
0% Town Hall, 53095 Main Road
TOWN CLERK ; A\ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS W Southold, New York 11971
MARRIAGE OFFICER : '�$ Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER '''-:5, 01-of Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER _ e *',1',,." southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD RECEIVED
SOUTHOLD WASTEWATER DISTRICT
OCT 12 2004
APPLICATION
OPERATION PERMIT Southold Ton Clerk
CESSPOOL or SEPTIC TANK
Residential @ $10or Non-Residential @ $25 Application No.0(01
Permit No.
Owner Name (card (4,401
Owner Mailing Address g OX &24
Aku Johlk NY 114x6
Owner Property Address aitgO re' cci ',€.&
ruw7v /1L /VJ11gc
Owner Telephone No. 6S / 7i/ 6q '7 ?
Se/-l/ye /?U' Caro — it7 - 0 ./ —1 `f
Tax Map No: /) Section Block Lot
Cross Street ( -,(247. O
44
Please check each thates: New Construction /
Alteration to Exiting System
Residential\/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.)
/ /4,4 1/.30/0
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Signature of � ,;,.__, t D to
Received by:
A- i. r
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I,
SARAH GOLDMAN
480 FRED STREET r
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