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HomeMy WebLinkAboutRadich SCUTHCLD VIASTEVIATER DI SPO6AL PERM T CPERATI CN PERM T SEPTI C TANG or CESSPOCL Oper at i on Per M t Nb. 4471-R Resi dent i al X %n-Desi dent i al Fee $ 10. 00 New X Exi st i ng Nacre Cf Ouuier KFJ TH & BARBARA RAD CH ------------------------------ Mai I i ng Address 1 3005 CLD JULE LADE ------------------------------ W ling Address 2 ------------------------------ Ci t y St Zi p IVATTI TUCK W 11952-0000 -------------------- -- ---------- Property --------- Property Address 1 2870 I-ENRY S LANE ------------------------------ Pr oper t y Addr ess 2 ------------------------------ Ci t y St Zi p PEOCN C W 11958-0000 -------------------- -- ---------- Owner Tel ephone Nb. 631-298-2046 ------------ Tax Map Nb. sect i on 74. 00 block 1 1 of 1. 000 ------ --- ------ Cross St r eet SCUD AVENLE ------------------------------ ---------------------------------- I ssue Date: 9/ 15/ 14 B i zabet h A Nevi I I e -------- Sout hol d Tom Clerk (TOM SEAL) O�OSVf f�(�►C ELIZABETH A. NEVILLE D Town Hall, 53095 Main Road TOWN CLERK via Z P.O. Box 1179 REGISTRAR,OF VITAL STATISTICS ORIAGE OFFICER ,L � Southold, New York 11971 Fax(631) -6145 RECORDS MANAGEMENT OFFICER y-7�• ��0�� Tele hone (63 65 P 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. 9 LI 7 Permit No. q2M._� Owner NameE�t Owner Mailing Address C7 Ly% Owner Property Address 1n Owner Telephone No. Q93K— 0Q0�A('n g© 0 Tax Map No: Section to ,00 Block Lot 0 Cross Street SO" ,-A 4N V\Cy`lE 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.) or.,A L4 A g � Signature of Apph t Da e Received by: