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HomeMy WebLinkAboutLicalzi SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 4450-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner LUKE LICALZI ------------------------------ Mailing Address 1 19 PROSPECT AVENUE ------------------------------ Mailing Address 2 ------------------------------ City St Zip GARDEN CITY NY 11530-0000 -------------------- -- ---------- Property Address 1 2105 CALVES NECK ROAD ------------------------------ Property Address 2 ------------------------------ City St Zip SOUTHOLD NY 11971-0000 -------------------- -- ---------- Owner Telephone No. 516-747-5069 ------------ Tax Map No. section 70.00 block 4 lot 46.001 Cross Street HARPERS ROAD ------------------------------ ---------------------------------- Issue Date: 12/28/12 Elizabeth A. Neville -------- Southold Town Clerk (TOWN SEAL) ELIZABETH A. NEVILLEo� Gy� Town Hall, 53095 Main Road TOWN CLERK ti Z P.O. Box 1179 REGISTRAR OF VITAL STATISTICS O Southold, New York 11971 MARRIAGE OFFICER y� • O�� 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 @ $10 or Non-Residential @ $25 Application No. Permit No. Owner Name z- Owner Mailing Address c /'V`r T/4-3 O Owner Property Address �"l© S <f,A Lye S ✓Ve c6- Owner Telephone No. 7 7 5-0 G /moo o -j 7 6). 5! t./(. C)n Tax Map No: Section Block Lot Cross Street /"R('Q,R S_ R i?'IA-D Please check each that applies: New Construction Alteration to Existing System Residentialy 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.) / "Z2 A rci rZ S ni0 -Scc R ve y S OA/ 11 _/2-�Z Signature of Ap Date Received by: "[