HomeMy WebLinkAboutReed SCUTHCLD VIASTEVVER d SPCGAL PERM T
CPERATI CN PERM T
SEPTI C TANK or CESSPOCL
Cper at i on Per rri t W. 4459-R Resi dent i al X Wn-Pesi dent i al
Fee $ 10. 00 New Exi st i ng X
Nacre Cf Ower JADE REED
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Mbi I i ng Addr ess 1 215 KRAUSE ROAD
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Mbi I i ng Address 2
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Ci t y St Zi p NATTI TUCK W 11952-0000
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Property Address 1 215 KRAUSE ROAD
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Pr oper t y Addr ess 2
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CI t y St Zip NATTI TUCK W 11952-0000
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Canner Tel ephone W. 631-298-5651
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Tax Mtp W. sect i on 122. 00 block 5 1 of 7. 000
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Cr oss St r eet CLD J L1LE LADE
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I ssue Dat e: 10/ 11/ 13 0 i zabet h A Navi I I e
-------- Sout hol d Tomn a erk
(TOaIN SEAL)
o�oSUFFoc,��,
ELIZABETH A.NEVILLE C y� Town Hall, 53095 Main Road
TOWN CLERK y P.O. Box 1179
REGISTRAR OF VITAL STATISTICS O Southold, New York 11971
145
RECORDS�MANAG MANAGEMENT OFFICER RIAGE OFFICERy� `1►aO�� Tele oFax ne 163 657665-1
Telephone( ) 5 800
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
y
Residential @$10 Vor Non-Residential @$25 Application No.
Permit No.
Owner Name (�
Owner Mailing Address
Owner Property Address OG l ✓�-(/-6 f
Iff
S
Owner Telephone No.
Tax Map No: ection Block Lot
Cross Street__ 4�' C�
Please check each that appli s: New Construction
Alteration to Existing System
Residential. � L 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 sF4 with SCHD roval.)
Signa tire of Applicant Date
Received by:
5
�Y
GeS�V