HomeMy WebLinkAboutOlsson, Frederick (3) e�```QF SU�jyo�,
ELIZABETH A. NEVILLE ' '`� 4 `
Town Hall, 53095 Main Road
TOWN CLERK glig P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ; G ,� Southold, New York 11971
MARRIAGE OFFICER Is r Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER cf,f- A ��
C �� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER OUNTV, ° southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4336-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FREDERICK OLSSON
Mailing Address 1 3 GLENWOOD AVENUE
Mailing Address 2
City St Zip HASTINGS-ON-HUDSON NY 10706-0000
Property Address 1 3280 NASSAU PT RD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 914-478-2130
Tax Map No. section 111.00 block 4 lot 3.020
Cross Street VANSTON ROAD
Issue Date: 5/14/07 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE $4` 4,, Town Hall, 53095 Main Road
TOWN CLERK 1 a ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS % yj, Southold, New York 11971
MARRIAGE OFFICER : '� 1� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER yqf a0.of° Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER -_----..,-,0'l * "e'.0 southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10or Non-Residential @ $25 Application No.433 t
Permit No. 352 a°'
Owner Name `------F-4 g r7t Rtv k 01 A3..
Owner Mailing Address ? (-L Ni t,� )C)( J4 i/e,
Nk s---ai4 - ) q4 /NY / 67b- •
Owner Property Address ?r. —s 01if-t l 1*A--rt---
-"7--SsO /1 sA w ( Al t,•L C is-v6_140.21 , 0 fci---
Owner Telephone No. 92 q—✓ l .6 --24-3()
30. a
Tax Map No: Section t I t , 0 D Block t+ Lot 0
Cross Street LM# St1 /f 7j
Please check each that applies: New Construction
Alteration to Existing System
Residential ✓' Non-Residential
NOTE: LOCATION MAP MUST RE stinainTED 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:J J., / 1 } zo
Signature of Applicant 1 ate I
Received Si '4 I D7
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