HomeMy WebLinkAboutKozen JUDr lI T. TERRY 'a Town Hall, 53095 Main Road
TOWN CLERK I P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �'��� Fax (516) 765-1823
MARRIAGE OFFICER ® .�
*z4 Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1949-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KOZEN, HENRY
Mailing Address 1 P. O. BOX 188
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1520 DONNA DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5007
Tax Map No. section 115.00 block 15 lot 14.000
Cross Street THERESA DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 7/23/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• ...
OFFICE OF THE TOWN CLERK ' PFFD
Town of Southold ��_ CQ Application No./7V(
Judith T. Terry, Town Clerk •� r
Town Hall, 53095 Main Road E s ! $-10.00 - Residential ��
P. O. Box 1179 `�� ";ri�. $25.00 - Non-Residential
Southold, New York 11971 O ® . � `
TelephoneIldit 0
(516) 765-1801
TOWN OF SOUTHOLD '
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ , >
DATE 6 6' �
OWNER NAME: INtriu }l 6-z
OWNER MAILING ADDRESS: Po I 7 /831/1jIfi7 '4 k
k9/)
OWNER PROPERTY ADDRESS-:— 4,52-0 bbel, 15 ;
or/Ye/40k ) iU
OWNER TELEPHONE NUMBER: �' d OO-2
TAX MAP NO. : Section /tc Block / Lot iy
CROSS STREET: ,/y6�b 4
TYPE OF SYSTEM: ' Septic Tank - New Existing
CesspoolP New Existing
Residential le' Non-Residential
DATE OF PREVIOUS PUMP-OUT: aidkN®u)
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.)
112P -/
Sign ure of Applicant
RECEIVED_BY:
Town Clerk's Office
DATE:
Do/UNig DA,
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