HomeMy WebLinkAboutWessell SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4480-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner LEONARD & AMY WESSELL
------------- ----------------
Mailing Address 1 2205 TOPAZ DR
------------------------------
Mailing Address 2
------- ----------------------
City St Zip BOULDER CO 80304-0000
-------------------- -- ----------
Property Address 1 12600 NEW SUFFOLK AVE
------------------------------
Property Address 2
------------------------------
City St Zip CUTCHOGUE NY 11935-0000
-------------------- -- ----------
Owner Telephone No. 000-000-0000
------------
Tax Map No. section 116.00 block 6 lot 13.000
------ --- ------
Cross Street BAY ROAD
------------------------------
------------------ ---------------
Issue
---------------------------------------------------------------
Issue Date: 2/18/15 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
I
Cap
ELIZABETH
ELIZABETH A.NEVILLE Town Hall,58095 Main Road
C*
TOWN CLERK to P.O.Box 1179
.s► Southold,New York 11971
REGISTRAR OF VITAL STATISTICS • 'F Fax(631) 765-6145
MARRIAGE OFFICER ��� �a� Telephone(631) 765-1800
RECORDS MANAGEMENT OFFICER southoldtown.northfork net
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATIOI\
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10—Lor Non-Residential @$25 Application No.�Z/
Permit No.
Owner Name h Q r� 0-rA-
Owner Mailing Address Z ZOS Co
t L� C
Owner Property Address 1 �.�fl� V -� 0 L rte
G(n-TCHOAuE-
Owner Telephone No.
Tax Map No: Section 1 Block Lot
Cross-Street_ PAI �>_K
Please check each that applies: New Construction
Alteration to Existing System
Residential_ _ Non-Residential
NOTE: LOCATION MAP NWST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
►aAS—
Signature of Applicant Date
Received by:
•� M �nc� M, oma'► ammna