HomeMy WebLinkAboutScholtz 1 ire Ise
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r. s Town Hall, 53095 Main Road
eZrP.O. Box 1179
-_477jJ Southold, New York 11971
JUDITH T.TERRY %„�iir%''`� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)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. 1504-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SCHOLTZ, DONALD AND NANCY
Mailing Address 1 P. O. BOX 106
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5168
Tax Map No. section 127.00 block 1 lot 2.00
Cross Street FRANKLENVILLE/ALDRICH LANE
Date Of Last Pump Out 0/00/00
Issue Date: 7/25/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III
OFFICE QF THE TOWN CLERK c3� tOur -
Town of Southold � ._ ��'� Applic`6tion No. /s—p�
Judith T. Terry, Town Clerk , i�
Town Hall, 53095 Main Road v _ -� $10.00 - Residential
P. O. Box 1179 &s.
:3r $25.00 - Non-Residential
Southold, New York 11971 O0 - 0���`
Telephone 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 7/20/9'0
'OWNER NAME: S �c d d'
OWNER MAILING ADDRESS: O 6
/11644 led L /LL (/q 4 if -
OWNER PROPERTY ADDRESS: /,�„.,,,e,/
OWNER TELEPHONE NUMBER: 5- (6
TAX MAP NO. : Section /2 7 Block 0/ Lot 2,,I
CROSS STREET: F7_ r o f C 76ZA,e:,1
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool New Existing X.
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: � 2‘ 0
LOCATION MAP: Must be attached hereto efore permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
•
— Signature o Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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