HomeMy WebLinkAboutRohrbach 001
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_ t Town Hall, 53095 Main Road
= ' P.O. Box 1179
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i‘' Southold, New York 11971
JUDITH T.TERRY _�� �,,�_►! FAx(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1409-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROHRBACH, GEORGE A.
Mailing Address 1 BOX 1155
Mailing Address 2
City St Zip MATTTIUCK NY 11952-0000
Property Address 1 1620 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4782
Tax Map No. section 107.00 block 3 lot 9.002
Cross Street WEST VIEW DRIVE
Date Of Last Pump Out 0/00/00
1201141;fle="410 _
Issue Date: 3/09/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold C A lication No.
Judith T. Terry, Town Clerk '*71:- Dig:i PP
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Town Hall, 53095 Main Road a ,w $10.00 - Residential
p, O. Box 1179 U' r i •
x �j ,. • $25.00 - Non-Residential
Southold, New York 11971 O0rF •
BOJ
Telephone j `j►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
tor
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE k5///9-6
OWNER NAME: CEO, a ii• ?ot/iegyfek/ //s-s- •
OWNER MAILING ADDRESS: /62* Sen/(4) ,4V¢
M9-777774iii ,y. / 9s2_
OWNER PROPERTY ADDRESS: Al-A5-1/,C, - -
OWNER TELEPHONE NUMBER: S76 Y9 e(73
TAX MAP NO. : Section - 3 Block C? Lot Z
CROSS STREET: bui..., U _
TYPE OF SYSTEM: Septic Tank New Existing
/
Cesspool t/ New Existing 1/
Residential I/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: i 13
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.)
a _ F,&LL__.
Sign ture of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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