HomeMy WebLinkAboutMolchan ;;' Town Hall, 53095 Main Road
$.3f=r3 1� P.O. Box 1179
7-r:41 10 ,��'' Southold, New York 11971
JUDITH T.TERRY r %loo FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 109-N Residential Non-Residential X
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner MOLCHAN, ROBERT
Mailing Address 1 2600 RUTH ROAD
Mailing Address 2 BOX 1197
City St Zip MATTTIUCK NY 11952-0000
Property Address 1 28970 ROUTE 25
Property Address 2 HARDWARE STORE
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-298-4675
Tax Map No. section 102.00 block 6 lot 22.000
Cross Street DEPOT LANE
Date Of Last Pump Out 0/00/00
Issue Date: 5/07/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK r
�t5I FOUr
Town of Southold Y� {��� s101j• Application No. n/� / j)1
Judith T. Terry, Town Clerk % a-4' a' y
'� 5 $10.00 - Residential
Town Hall, 53095 Main Road a p` ,‹44 :< '
P. O. Box 1179 - c' K):•.;,4
.
�. �t �. $25.00 - Non-Residential /
Southold, New York 11971 O ' ® =� , "O�,-
Telephone _Q( *6
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD 'WASTEWATER DISPOSAL DISTRICT
APPLICATION
- _, ,_ _ ..- -
For
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 0-5/9'0
OWNER NAME: n/ A 7L / o/cA ,i
OWNER MAILING ADDRESS: 2_,C00 1.i ki_ My if//c./_A/ r // a_
- - - - - -- - OWNER--PROPERTY ADDRESS:- 8.i70 R toZ - /4c Rd:
r,tdotrjod
OWNER TELEPHONE NUMBER: cc-&C (2q -#C77
TAX MAP NO. : Section /O Block or Lot 0o2.0L,
,
CROSS STREET: pep �-f /-44/e-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing 1
Residential • Non-Residential 7
DATE OF PREVIOUS PUMP-OUT: 3/:73- qG
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.)
Alet,fni/i4
Signature of Applicant
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RECEIVED BY: i'i � f
' own '' I-rfffr%"- ice
DATE: (.._.. .2740l
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