HomeMy WebLinkAboutGohorel 4. a � ANNO IM IT
JUDITH T. TERRY F Town Hall, 53095 Main Road
TOWN CLERK . ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS WI) �` Southold, New York 11971
MARRIAGE OFFICER
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T. Fax (516) 765-1823
® � 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. 1954-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GOHOREL, JANE M.
Mailing Address 1 P. O. BOX 128
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 1870 STARS ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2139
Tax Map No. section 22.00 block 4 lot 18.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 8/05/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE 'OF THE TOWN CLERK 1c31FO(,(�C;• _
Town of Southold �� .. Q - Application No. (F,5-X
4
Judith T. Terry, Town Clerk T s
Town Hall, 53095 Main Road < - $10.00 Residential
p. O. Box 1179cn - ` ► �` $25.00 - Non-Residential
Southold, NewYork 11971 O x y -q•
•�`
Telephone .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE gkh.5.-
OWNER NAME: --/:}/N& A4. 6'01-iD ,REL
OWNER MAILING ADDRESS: / • 0. a•
k.—A.sr- M4 Rio Al //5 9 _.V .
OWNER PROPERTY ADDRESS: ST-4,4g
EiisT 04/44,6ti N. y. //city
OWNER TELEPHONE NUMBER: .06 - 477- e2131
TAX MAP NO. : Section �4._ Block Lot /1
CROSS STREET: //G2i.;-c)
TYPE OF-SYSTEM: -Septic- Tank-- --�= -New Existing
Cesspool V ' 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.)
.17 ...2"4—'2--R
Signature of Applicant
RECEIVED_BY: - -
ow Clerk's Office - =
DATE: ��
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