HomeMy WebLinkAboutSamolewski, Robert OFFICE OF THE TOWN CLERK CO FOI`C
TOWN OF SOUTHOLD OSS �+i OG Application No. 14.217ELIZABETH A.NEVILLE,TOWN CLERK
.4 ; $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 �,� $25.00 - Non-Residential
Telephone �j `j►� �'
(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: Kobert
OWNER MAILING ADDRESS: 7 OD f ' Lek ,
91e,,/fiy f(aI5
OWNER PROPERTY ADDRESS: 6'W Ali' S(A ,
GHQ ,NY ((Qis-
OWNER TELEPHONE NUMBER: 6fr— 73y S (7'
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TAX MAP NO. : Section /c7/
Block bpo l Lot 3
CROSS STREET: cD(i4/ 4, y,s7
TYPE OF SYSTEM: Septic Tank X New X Existing
Cesspool X New X 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.)
z, 44.
ignature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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Town Of Southold
P.O Box 1179
► Southold, NY 11971
* * * RECEIPT * * *
Date: 07/23/03 Receipt#: 386
Transaction(s): Subtotal
1 Septic Permit- Operation - Resid. $10.00
Check#: 386 Total Paid: $10.00
Name: Samolewski, Robert
7800 Alvahs La.
Cutchogue, NY 11935
Clerk ID: LINDAC Internal ID:79829
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