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HomeMy WebLinkAboutSchmidt - r #, ._F. IIT®Off GL4' ^ JUDITH T.TERRY ` © r;-z �%ritr V, Town Hall, 53095 Main Road TOWN CLERK ` ' ' t ; P.O.Box 1179 '4'444 °� �� Southold,New York 11971 REGISTRAR OF VITAL STATISTICS �,t., �1� Fax(516)765-1823 MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER ''' ®• 0 4:� = ie Telephone Telephone(516)765-1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3348-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner SCHMIDT, HELENE Mailing Address 1 P. O. BOX 843 Mailing Address 2 City St Zip GREENPORT NY 11944-0000 Property Address 1 62675 NORTH ROAD Property Address 2 City St Zip GREENPORT NY 11944-0000 Owner Telephone No. 516-477-1832 Tax Map No. section 40.00 block 1 lot 9.000 Cross Street CHAPEL LANE Issue Date: 6/12/95 Judith T. Terry Southold Town Clerk (TOWN SEAL) - Ay OFFICE Or THE TOWN CLERKc��FFair Town of Southold , � : ^ CQG�;, Application No. -' / Judith T. Terry, T cwn Clerk Town Hall, 53095 Main Road °', -� ) $10.00 - Residential /0,4,6 P. 0. Box 1179 $25.00 - Non-Residential Southold, New York 11971 Nr Telephone 01 0 * �� (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. /p, 01) Fee $ DATE // .//7 t 2 i /9 f, OWNER NAME: y e,-- OWNER MAILING ADDRESS: 9/fie-e�A�6; /1/', �, //7 ”'(l Po. i >( S-g3 OWNER PROPERTY ADDRESS: dit4 ,e1174., /?vGeq' (( 7 ;- 7\ OWNER TELEPHONE NUMBER: `i477 —/S(. 30Z TAX MAP NO. : Section LAO Block ( Lot CROSS STREET: TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing d� Residential V Non-Residential 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.) Sign ture of Applicant RECEIVED BY: Tog 's Office DATE: JUN 1995 T®wry Cletit Soutft 11