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HomeMy WebLinkAboutSpurge SC LfrFICLD VIASTEVIATER a SPOSAL PERM T CPERATI CN PERM T SEPTI C TAN( or CESSPOCL Cper at i on Per M t W. 4470-R Resi dent i al X Non-Resi dent i al Fee $ 10. 00 New Exi st i ng X %rre Cf Ower NANC'Y'/TFICI M SPIE CPRr ------------------------------ Mai I i ng Address 1 300 W 23RD ST, APT 12D ------------------------------ Nbi I i ng Address 2 ------------------------------ Ci t y St Zi p N=1N YCRK w 10011-0000 -------------------- -- ---------- Pr oper t y Address 1 3145 RANHWSEIT AWME ------------------------------ Property ----------------------------- Property Address 2 ------------------------------ 0 t y St Zi p CPEENPCRT W 11944-0000 -------------------- -- ---------- Owner Telephone W. 917-301-5870 ------------ Tax Map W. sect i on 43. 00 block 1 1 of 7. 000 ------ --- ------ Cr oss St r eet ANGERS ROOD ------------------------------ ------------- -------------------- I --------------------------------------------------------------- I ssue Date: 5/20/ 14 B i zabet h A Nevi Ile -------- Sout hol d Tom C1 erk (TOAN SEAL) o�oS�FFot�.�, OG ELIZABETH A. NEVILLE �� �� Town Hall, 53095 Main Road TOWN CLERK t�i� Z P.O. Box 1179 REGISTRAR.OF VITAL STATISTICS O Southold, New York 11971 MARRIAGE OFFICERy • O�� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER �01 �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. �3�✓� Owner Name Owner Mailing Address_ _ 31:>D w 2; 'a ST p�qt- ILD 01 ; 0"-A'^ 100 ( 1 Owner Property Address J�1 5 /V l(� L h 6d f, Owner Telephone No. Tax Map No: Section �J ©b Block Lot 7 Poo Cross Street AVIer5 o d Please check each tha applies: New Construction / Alteration to Exis ing System 1/ 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.) Signature of Applic t Date Received by: t ' r Suffolk t oonty DePurtmecct M in"c" ol'ilee�WasteWstr'M• t sWolk kXMMY mverhead,New York 11901 (631)852-2100 CERTIFICATION OF SEWAGE DISPOSAL SYSTEM'BY IN YALlASx lIealth Department Kelerattx rtumuw.'— Suffolk Tax Map#: Dist—MOD—se f_ ls) 15 Project Name or Address' Subdrvtstod Ntame et Loc ApplicaWs Name: Description of System installed: Septic Tank ` 000 O0 Volume(gallons) Ste; &,ectangubw [l Cylindrical NW, Of rreR:M tvutuuuAAA"&%-4. Leaching Fools Number of Pools Lhameter ana LMpm 2' L x `� Name of Precast Manufacturtx: Other: Attach or sketch below the measuts from bWlding to the SOCX: s Covers of atapoM syscrru. Ph A (3 ' 3 Sr aescdhe l hada.has been imtatten bY me m aeea� i 11Ct+ arn[1r than the sabwrface�CWagC d�pamiws • ..r udbalth Com.,kvw menti ix anetatronal. WIUI the apptu p eau w Date — 7 -� l3 installer Signature: phot Ynm 1'IitEUCI AMIStMuy r • Consumer Affairs License Number: �- This t ertitkation be u9A M HM of ttMedfons Mphvdb1 rmovidof the Dgartf �t and *m ♦be �on Company k"Whend,p��It eouta�the a�bore ddormntion. WWM-ora (UMI)