HomeMy WebLinkAboutJP Modular Homes (2) SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4446-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner J P MODULAR HOMES
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Mailing Address 1 131 HICKS STREET
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Mailing Address 2
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City St Zip BROOKLYN NY 11201-0000
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Property Address 1 5503 MAIN BAYVIEW ROAD
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 718-624-0386
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Tax Map No. section 78.00 block 7 lot 5.006
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Cross Street SMITH DRIVE SOUTH
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Issue Date: 11/16/12Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
ELIZABETH A. NEVILLE y� Town Hall,53095 Main Road
TOWN CLERK 6* Z P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS O � Southold, New York 11971
MARRIAGE OFFICER A • a��� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER 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 @ $10 )or Non-Residential @ $25 Application No3 J -<;-4-
Permit No.
Owner Name C")1� �/" ' z�-- � �! �� /� CI
Owner Mailing Address r / ��C 5 57- e�0 0�t" " / ! DI
Owner Property Address
SaUT�a� �
Owner Telephone No. F O 3 'g- 6
Tax Map No: Section 7q ' o` Block —7 Lot >7P b
Cross Street 7L (-� I T J P/z U4� �-5 d
Please check each that applies: New Construction
Alteration to Exip6ng 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.)
Sigr,Wure of Applicant Date
f�
Received by:
Town of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 11/16/12 Receipt#: 143345
Transaction(s): Reference Subtotal
1 1 Septic Permit-Operation - Resid. 4445 $10.00
Cash Total Paid: $10.00
Name: Toth, Vicki
425 Jacobs Lane
Southold, NY 11971
Clerk ID: CAROLH Internal ID:4445