HomeMy WebLinkAboutKlein Fri N
Vcf, Town Hall, 53095 Main Road
`Y®A,® _&i P.O. Box 1179
10' Southold, New York 11971
JUDITH T.TERRY � �ir�/l'°�� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1505-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KLEIN, GERTRUDE
Mailing Address 1 780 HOLDEN AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 780 HOLDEN AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5049
Tax Map No. section 110.00 block 5 lot 19.000
Cross Street SOUTHERN CROSS
Date Of Last Pump Out 0/00/70
Issue Date: 7/25/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c0FO(,r�'- •
Town of Southold �� ,- C'� Application No. /,5- g
Judith T. Terry, Town Clerk . 4. =ti zi% ►:`
53095 Main Road $10.00 - Residential ✓
Town Hall,
P. O. Box 1179 v7z s�,� i
��.., , � $25.00 - Non-Residential
Southold, New York 11971 O ® _,*', , �`
Telephone 01 `���,0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. - -
Fee $ •
• DATE v� ` ZC.) / 9P0
PO
OWNER NAME: g5/0790 be- X``e.F •
OWNER MAILING ADDRESS: 780 /IoLbenI /4- "V
arc.o a v e iVy
- - -- - OWNER PROPERTY -ADDRESS:
OWNER TELEPHONE NUMBER:
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TAX MAP NO. : Section // O Block ' Lot 1 7
CROSS STREET: So VTC., c14_1.-44
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing /
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: '97o ,
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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