HomeMy WebLinkAboutKozora, Judy N
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4329-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner JUDY KOZORA
Mailing Address 1 64920 C.R. 48
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 3470 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-477-5067
Tax Map No. section 79.00 block 2 lot 300
Cross Street PINE NECK ROAD
Issue Date: 12/14/06 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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_ , ELIZABETH A.NEVILLE i ~ A ; Town Hall, 53095 Main Road
TOWN CLERK a P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ::O . 1% Southold,New York 11971
MARRIAGE OFFICER ' '* 0.,erft' Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER --__RI Jig it" 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 or Non-Residential @$25 Application No.' 13a 1
Permit No. __
Owner Name Sud 1 KOZ C, r a`.
Owner Mailing Address fi 412- 0 Ia.d fC 4 g
14-10
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Owner Property Address �b r+\-- v VI- ?...S.)-- ,
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Owner Telephone No. LiO 2 rl 50 Io-
Tax Map No:17 3Wt Sections t01 l Block %%% Lot 003 .N5
P—PNCross Street 1 YU- C L K R \/
Please check each that applies: New Construction J'.
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.)
49ry -..._` /- 3 ar.‘
Signature o • p.licant Date
Received by:
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