HomeMy WebLinkAboutKempner, Ann (2) SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4322-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner KEMPNER, ANN
Mailing Address 1 PO BOX 1718
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 270 GOLDIN AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-765-3473
Tax Map No. section 135.00 block 2 lot 21.000
Cross Street
Issue Date: 9/25/06 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
ELIZABETH A.NEVILLE ��h`L`O .y 1 Town Hall, 53095 Main Road
TOWN CLERK ` 2 ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS j, Southold,New York 11971
MARRIAGE OFFICER '� 1� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER %=-W0
y V.0 Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER `' �'� ��•'' southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
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Residential @$10 or Non-Residential @ $25 Application No. ✓
Permit No.Z 1(0 1
Owner Name ñ,V,Viti- 2
Owner Mailing Address /i0 i l7, 2
..Sva� ) A J 1/97,
Owner Property Address '7 6 ti17/�f
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Owner Telephone No. ‘,3i 7I ,37,?_)
Tax Map No: Section 12E Block CQ Lot a I
Cross Street
Please check each that applies: New Construction
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 from system to building
and closest road. New construction may submit cop of survey with SCHD approval.)
\77.
Signature of Applicant a e
43
Received
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