HomeMy WebLinkAboutDomaleski OFFICE OF THE TOWN CLERK ' i�1FUCKc" •
Town of Southold , � _ �G
Judith T. Terry, Town Clerk ; Z ;:
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Town Hall, 53095 Main Road .-
P. 0. Box 1179
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Southold, New York 11971 • O ®_ "'_ f '�
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Telephones
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 113 Residential x
Non-Residential
Fee $ 10.00
Septic x Cesspool x
NAME OF OWNER: Henry Domaleski
OWNER MAILING ADDRESS: 8245 Oregon Road
Cutchoque, New York 11935
OWNER PROPERTY ADDRESS: 8245 Oregon Road
Cutchoque, New YOrk
OWNER TELEPHONE NUMBER: 516:-734-6886
TAX MAP NO. : Section 95 Block 1 Lot 12
CROSS STREET: Depot Lane
TYPE OF SYSTEM: Septic Tank X New Existing x
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: December 1985
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Judith T. Te
Southold Town Clerk
DATE: October- 29, 1986
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OFFICE OF THE TOWN CLERK FO(,�,,
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Town of Southold & ' 4.� CQG•-' Application No. �/3
Judith T. Terry, Town Clerk ` p C* ,
Town Hall, 53095 Main Road „ zt
--G 1 Residential
P. O. Box 1179 E' �4 � : Non-Residential
Southold, New -York 11971 O fa, ' $
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Telephone V..(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEIVEDAPPLICATION
OCT 2 91986 for
Town Clerk Souti1016 OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. //3
Fee $ /6'--
DATE /7c=2-77P6/
OWNER NAME: fez ry t�n 36i/ecs /Ci, Q
OWNER MAILING ADDRESS: f02.'75✓ )reta r) Ie9 aJ
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OWNER PROPERTY ADDRESS: SaG�- nQ�
OWNER TELEPHONE NUMBER: 22 '/' ‘ d7
TAX MAP NO. : Section 7S Block / Lot / —
CROSS STREET: Apoq-- ILa_ive _,
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool p2_/ New Existing
Residential �/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: , 3ea-elm6.ep-, /9/S
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.)
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ij71/34--4-a—'
/ Sigliture of Applicant
RECEIVED BY: = -�- C��(
Town lerk's ffice
DATE: 6- w c)99, / f