HomeMy WebLinkAboutFujita, David (2) � ,''
ELIZABETH A. NEVILLE / h� lQ Town Hall, 53095 Main Road
TOWN CLERK Ali *, P.O. Box 1179
REGISTRAR OF VITAL STATISTICS N Southold, New York 11971
MARRIAGE OFFICER Fax 1� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER A lof Telephone (631) 765-1800
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FREEDOM OF INFORMATION OFFICER = COUIC ,� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4286-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner FUJITA, DAVID
Mailing Address 1 1655 PARK WAY
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 20 MECHANIC STREET
Property Address 2
City St Zip SOUTHOLOD NY 11971-0000
Owner Telephone No. 631-765-3034
Tax Map No. section 61.00 block 4 lot 32.000
Cross Street MAIN ROAD
Issue Date: 7/08/05 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE i Town Hall, 53095 Main Road
TOWN CLERK ` Z ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ”;O'y .4/ Southold, New York 11971
MARRIAGE OFFICER %.44/
Fax Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER l * `t►ost 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 .7or Non-Residential @$25 - Application No.q9--
Permit No. 7,05—
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Owner Name )av"`A
Owner Mailing Address 1 (a Cc. Pa..(L tA54.1
d,3y if
Owner Property Address 20 An,eA,►ak. . ,
5 � -t,�IdL e-rr _ 1 tc?!
Owner Telephone No. (4 - Z03
Tax Map No: Section L t .ay. Block 4, Lot 3 2,
Cross Street /V1a 12-k,
Please check each that applies: New Construction
Alteration to Existing 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.)
Dez,4-tot /t,4, b /2 3i®Signature of App?A:7'4
t Date
Received by: