HomeMy WebLinkAboutPotorski, Joseph .. ,- _ y�
OFFICE OF THE TOWN CLERK FFO yTOWN OFSOUTHOLD 0� -SG Appi
ELIZABETH A.NEVILLE,TOWN CLERK $10.00 - Residential
P.O.BOX1179
SOUTHOLD,NEW YORK 11971 ,�� $25.00 - Non-Residential
Telephone Yfe.i * 071/4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: .: (E 1/ t'6TQRSI
OWNER MAILING ADDRESS: 34 RIDG ILD
Fn2M?NG-D LE m9 11735
OWNER PROPERTY ADDRESS: 10 71-1P's i i
SOl oLD /vy
OWNER TELEPHONE NUMBER: (51 (0) a613- Q3) 5
TAX MAP NO. : Section 7 f Block 3 Lot g-
CROSS STREET: A/paw?f ,BA`V ', lee,417
TYPE OF SYSTEM: Septic Tank New X Existing
Cesspool New Existing
Residential Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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JOHN C. EHLERS LAND
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6 EAST MAIN STREET
RNERHEAD,N.Y. 11901
369-8288 Fax 369-8287 REF.—\\Hp server\d\PRO5
Town Of Southold a
P.OBox 1179
• • Southold, NY 11971
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* * * RECEIPT * * *
Date: 08/14/03 Receipt#: 0
Transaction(s): Subtotal
1 Septic Permit- Operation - Resid. $10.00
Cash Total Paid: $10.00
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Name: Potorski Jr., Joseph & Suzanne
34 Ridge Rd 1
Farmingdale, NY 11735
Clerk ID: LINDAC Internal ID:80966
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