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HomeMy WebLinkAboutWielt • o'c 14.1(\, pYOS' -1,� JUDITH T. TERRY ;%. ts Town Hall, 53095 Main Road TOWN CLERK f P.O. Box 1179 REGISTRAR OF VITAL STATISTICS Southold, New York 11971 Fax 516 7 -1823 MARRIAGE OFFICER s �" ( ( ) 65 ��3��� �•' Telephone (516) 765-1801 iii. �I OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1798-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner WIELT, WARREN Mailing Address 1 P. O. BOX 66 Mailing Address 2 City St Zip LAUREL NY 11948-0000 Property Address 1 4205 MAIN ROAD Property Address 2 City St Zip LAUREL NY 11948-0000 Owner Telephone No. 516-298-8343 Tax Map No. section 125.00 block 1 lot 9.000 Cross Street ALDRICH LANE Date Of Last Pump Out 0/00/00 Issue Date: 11/04/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) • OFFICE OF THE TOWN CLERK C�FF�(�,'. Town of Southold Application No. /, 1%,e Judith T. Terry, Town Clerk �` 4 % Town Hall, 53095 Main Road s } .- $10.00 - Residential p. 0. Box 1179 cr3 ?x � i �,..,. $25.00 - Non-Residential Southold, New York 11971S 0 �0� ' Telephone 1 4c p� (516) 765-1801 TOWN`OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ /c0 , o© • DATE /////1/ OWNER NAME: W 4Q Eiv l LL?— OWNER MAILING ADDRESS: /O 66 1-4 L j iv—V. f1 '4(&' OWNER PROPERTY ADDRESS: 4',toS 42/4/4/ fir.4 2I95iT' OWNER TELEPHONE NUMBR: TAX MAP NO. : • Section 1_ S Block / Lot 7 CROSS STREET: M./gi(,- TYPE OF SYSTEM: Septic Tank • New Existing Cesspool ✓ New Existing Residential i/ 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: Town Clerk's Office DATE: I • .,/,',,:: I1 r - - - ! 4 i _ _ ±T - . i — . , ( J. Cr/ 1. 4 '� - �; ~ 0� / • J ' i ~ I (...-Z.30(rc*i.e. i :\ �� -, _hjnck { , '�ij , { Avr+,,r„�:ALN+ �+ `i% _iti(1,-. r • o atI • - •,el / - . .. / ' V I 1 I