HomeMy WebLinkAboutFohrkolb JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK - _1 Southold, New York 11971
P.O. Box 1179
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REGISTRAR OF VITAL STATISTICS '; ,
MARRIAGE OFFICER }f - Fax (516) 765-1823
Y_✓'� ~t Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1597-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FOHRKOLB
Mailing Address 1 670 HOLDEN AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 670 HOLDEN AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7087
Tax Map No. section 110.00 block 5 lot 20.000
Cross Street DICKS POINT ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
141 - 3- / 7
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3 tOFCE •OF THE TOWN CLERK ' •�
Town of Southold C' A lication N .
per -, -., :..�G Pp
Judith T. Terry, Town Clerk - 0 :'�
Town Hall, 53095 Main Road •X'�s N :G $10.00 - Residential
P. O. Box 1179 cr' ''�;>` 1 �r;; ';
,45-, ,;; ' �. $25.00 - Non-Residential
Southold, New York 11971 P t® A '' . �J
Telephone _01 0 JIG •I
(516) 765-1801
• TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE �
OWNER NAME: NtIer to '1(0,_&
• OWNER MAILING ADDRESS: Vf° 0°'-'1:"&, Ale-.
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PROPERTY ADDRESS: `--
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OWNER TELEPHONE NUMBER: Ct.0 ' �S`, ' 1'O O
TAX MAP NO. : Section /lD Block S� Lot ZO
CROSS STREET. b 1- ` O"4A--- 12-7 -
TYPE OF SYSTEM: Septic Tank New Existing "-----
Cesspool New Existing
Residential 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.)
0 I -
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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