HomeMy WebLinkAboutDeerkoski (3) �'' O\ /r
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JUDITH T. TERRYTown Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971 •
MARRIAGE OFFICER ®� 04 Fax (516) 765-1823
44io Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3093-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DEERKOSKI, FELIX AND PETER
Mailing Address 1 P. O. BOX 248
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4.600 ELIJAH LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8098 •
Tax Map No. section 101 .00 block 1 lot 2.003
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cvFFOUr '-
Town of Southold &4J - CQ Application No. 3O 23
Judith T. Terry, Town Clerk % it �+ ,./
Town Hall, 53095 Main Road - -� $10.00 - Residential
P. O. Box 1179 tri `� '.") .• *.•`�` $25.00 - Non-Residential
Southold, New York 11971 %O ® t'-`=i
Off',••
Telephone 0.( * ')
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE P4/9 a
//
OWNER NAME: retIX I t%?e 'kaski' 4- e,-4-ems . coeckosk, P
OWNER MAILING ADDRESS: po, Boge .„.7.,q,
rYa, 4-,`-1-u_c. - Ivy 1/95-a
-OWNER PROPERTY ADDRESS:`•` O1j F.-I 'o.i► LaiYI.('_ -- -- - -
MC--t--4-;4 c ck, /v V //9s-a
OWNER TELEPHONE NUMBER: c719e- rOgs"
TAX MAP NO. : Section Block ANt / Lot .4k1',71, 3
CROSS STREET: fCoft e— *k
• TYP,E;OF-_SYSTEM: Septic--Tank ra, - New Existing /,O
Cesspool New Existing
Residential .✓/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: `
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.)
041/ I)
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Signature of Ap licant
RECEIVED BY: (.10/a-4,----_,- '
To n Clerk's Office
DATE: - g /73
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