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HomeMy WebLinkAboutFohrkolb (2) 1I1 '.. MLA- t ca Town Hall, 53095 Main Road Otfv ; P.O. Box 1179 *_ � 0 ,! Southold, New York 11971 JUDITH T.TERRY % % '''�� FAX(516)765-1823 TOWN CLERK TELEPHONE(516)7654801 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. 1488-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner FOHRKOLB, ANDREW C. Mailing Address 1 P. O. BOX 645 Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 11955 SOUND AVENUE Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 516-298-5527 Tax Map No. section 141 .00 block 3 lot 17.000 Cross Street LIPCO ROAD Date Of Last Pump Out 0/00/00 Issue Date: 6/26/90 Judith T. Terry Southold Town Clerk (TOWN SEAL) CFICE OF THE TOWN CLERK �FFO ��� • Town of Southold �� COIj- Application No. . %%%- Judith T. Terry, Town Clerk 4;1k7, }t •1 $10.00 - Residential Town Hall, 53095 Main Road � �� �` <,;� . P. O. Box 1179 cry ' ' Yf ,-, ; $25.00 - Non-Residential Southold, New York 11971 �J� Telephone *j 4 �� (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $/O, ©O DATE J /2e 6, /990 OWNER NAME: 4nUYe C'• FOhrko/b • • • OWNER MAILING ADDRESS: Pa Box IONS /4a74Tifccck, /I/- y, 1/952 OWNER PROPERTY ADDRESS: 11(155 Sound Ave- / 1 a H- -,'4-uc-k N y //452 OWNER TELEPHONE NUMBER: (57 67 2 98- 5527 TAX MAP NO. : Section iv Block 3 Lot /7 CROSS STREET: 125 L /PCO Rd , TYPE OF SYSTEM: Septic Tank X New Existing X Cesspool x New Existing x Residential x 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.) 01„..Signature of Applicant RECEIVED BY: , ( 04e)/( 1'1-2' ow Clerk's Office f - DATE: 9-0 / 9Q -_--___----- - . � . '.. ` . '. . '- � / . ' 1' /