HomeMy WebLinkAboutWolczok, Mary Ann t _
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ELIZABETH A.NEVILLE 1'�,�`l`� �4\ Town Hall, 53095 Main Road
TOWN CLERK t a , P.O. Box 1179
y Z Southold New York 11971
REGISTRAR OF VITAL STATISTICS � v. Af i '
MARRIAGE OFFICER : .� I� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER = �� a0li��� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER = '/ 1'' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
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Residential @ $10 V or Non-Residential @ $25 Application No.
Permit No.
Owner Name rn 'Ry AA/A, &O4C2Ok. 4&n ( S10 rWDLCZOK.
Owner Mailing Address , . 6,1' A-v +P
Fti-2n" .vr7 bA- e N Y.
Owner Property Address t 9-€0 S i 6 S Qe e 'Je�
Ill 4- TT, Tv r�� /1/ y
Owner Telephone No. 3 14. L '74'-;-7 8 9 7
Tax Map�SNo:
1/00 0 0 Section I v�(rf Block 0( Lot (3
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Cross street ASO ype�) B y /1,4jN � Oa/ /Vo2f/,/ IfAib pecc '/c 84-Y
�-V D art c H e _co v 7-14.
Please check each that applies: 'New Construction
Alteration to Existing System ✓
Residential V 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.)
eW71-7494---
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Signature Applicant ate
Received by:
JOHN WOLZCOR
1880 SIGSBEE ROAD
MATT ITUCK
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