HomeMy WebLinkAboutLeiblein c % l ElLA . —
�' �' -r Town Hall, 53095 Main Road
JUDITV T. TERRY �,o„ , .? , o
TOWN CLERK ® •.•:4 "T • I P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Y ., .` Southold, New York 11971
,cP> t Fax (516) 765-1823
MARRIAGE OFFICER � ®���1 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. 1862-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LEIBLEIN, GARY C.
Mailing Address 1 2000 KENNY ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2000 KENNY ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3321
Tax Map No. section 59.00 block 3 lot 15.000
Cross Street CHESTNUT ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/31/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF, THEQ)�;. CLERK
PFFD
Town of Southold ��5CQ -,• Application No.
Judith T. Terry, Town Clerk
Town.4-Iall, 53095 Main Road 8 ` 7 $10.00 - Residential
P. O. Box 1179 cn ' tri .`' $25.00 - Non-Residential
Southold, New York 11971 OO �0 ��`
Telephone : . to
( •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
•
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0. °)
DATE 3" 36 "6
OWNER NAME: C
OWNER MAILING ADDRESS: p2O06 � 4, f
OWNER PROPERTY ADDRESS: cj/ rl
OWNER TELEPHONE NUMBER: 7 5 - 332-i
TAX MAP NO. : Section ' Block -.3 Lot /�
C�
CROSS STREET: � oa7 `et)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing Alf
Residential /1 Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
E E 1VED Signature of Applicant
• Cay
MAR 3 01992
RECEIVED BY:
Southold Town Clerrklerk's Office
DATE: •
St,` "4,0
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