HomeMy WebLinkAboutSchelin ii
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Town Hall, 53095 Main Road
!® O .$ P.O. Box 1179
'-_:*/ I Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TQWN CLERK TELEPHONE(516)765-
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. 1017-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHELIN, ROY A.
Mailing Address 1 P. O. BOX 1498
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 385 LOCUST LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3868
Tax Map No. section 62.00 block 3 lot 34.000
Cross Street KORN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/10/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c0FULA- 'v ,
Town of Southold �� CQ Application No.
Judith T. Terry, Town Clerk �A � rt
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Town Hall, 53095 Main Road a s` Residential
P. O. Box 1179 cL>a .
�;'' Non-Residential
Southold, New York 11971 O '� 1�`
Telephone 0.( Y►��.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /6/7
Fee $ /b '—
DATE tYof 0),./2
r
OWNER NAME: AV y /9 r /n/
OWNER MAILING ADDRESS: 9'°' 0' oeo)/
t./DefT,}o,.L IVY
OWNER PROPERTY ADDRESS: " .0 z
t •O Gc Th-0,4,6
OWNER TELEPHONE NUMBER: /1.5= J11
TAX MAP NO. : Section Block - Lot
CROSS STREET: fraeff Ao19Z t..
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Y 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.)
Signature of Applicant
RECEIVED BY: •
ii, -
' .0 " ,iTown Clerk's Office
DATE: F E B y, li tL'r J ,u 4 �
��:� ,, ��. FEB 1 01989
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