HomeMy WebLinkAboutFredrikkson SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4370-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FREDRIKKSON, JIM & ELAINE
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Mailing Address 1 195 YOUNGS AVENUE
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 195
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Property Address 2 YOUNGS AVENUE
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 631-765-0000
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Tax Map No. section 61.00 block 4 lot 3.810
Cross Street ROUTE 25
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Issue Date: 2/14/08 Elizabeth A. Neville
------ Southold Town Clerk
(TOWN SEAL)
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- ELIZABETH A.NEVILLE a Town Hall, 53095 Main Road
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.r TOWN CLERK = P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O Southold, New York 11971
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MARRIAGE OFFICER TijJ ` ��� Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �l � �a Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $l0—zor Non-Residential @ $25 Application No.0- 0
Permit No. _ \
Owner Name
Owner Mailing Address
Owner Property Address
Owner Telephone No.
Tax Map No: nn Section ( o j. ..c»Block _ Lot , }
Cross Street YA . Qs
Please check each that applies: New Construction
Alteration to Existing System ✓
Residential ✓ Non-Residential
NOTE: LOCATION MAP MUST 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.)
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Signature of Applicant Date
Received by:
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