HomeMy WebLinkAboutKot ,l' OFFOUr
JUDITH T.TERRY � _ Town Hall, 53095 Main Road
TOWN CLERK - P.O. Box 1179
,a. r � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER \-:** ®� �1�' Fax(516)765-1823
RECORDS MANAGEMENT OFFICER i ( igg too Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,••'�
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 156-N Residential Non-Residential X
Fee $ 25.00 New Existing - X
Name Of Owner KOT, LISA PETERS
Mailing Address 1 28E JOBS LANE
Mailing Address 2
City St Zip SOUTHAMPTON NY 11968-0000
Property Address 1 FRANKLINVILLE RAOD
Property Address 2 "HORSE HAVEN"
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-287-7065
Tax Map No. section 125.00 block 2 lot 1 .025
Cross Street ALDRICH LANE
Issue Date: 6/14/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
F •1 I
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OFFICErbF THE TOWN CLERK 'S�FFp ''-
L; Town of Southold �� • CQG:` Application No.,/le\ 19'
Judith T. Terry, Town Clerk �� , .. ? y
Town Hall, 53095 Main Road a ': -"4 $10•.00 - Residential
P. O. Box 1179 tr3 :i1; ` ;` $25.00 - Non-ResidentialW
Southold, New York 11971- O O° '\
Telephone - 1 WY:
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION � -
1 •
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATEg. _'
OWNER NAME: 1,...,15(4- 1)07-67/2S RAS ) -r
IP `
OWNER MAILING ADDRESS: j 410.
334 \Cap%
-OWNER-- PROPERTY ADDRESS:
1 r•e_ ' 'N‘ -
OWNER TELEPHONE NUMBER: ,L3I, • ,33,-) . loco5—
TAX MAP NO. : Section I cif Block Lot I , 2r—
_CROSS STREET: Abrich h 1)
TYPE,OF SYSTEM:-- Septic'Tank '- - •--New Existing ✓
Cesspool New Existing
Residential Non-Residential
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.)
l
Signature of Applicant
/7;
H-
REçEIvEDBY:
Tow 411-66466"Clerk's Office ®" arn
DATE. - . 6 U