HomeMy WebLinkAboutDoroski -.-
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JUDITH T.TERRY 1�� 4 Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
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4 i Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
' ��� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER = ®./ 4, `1°a®,�•� Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3518-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DOROSKI, GREGORY
Mailing Address 1 P. O. BOX 520
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1030 COUNTRY CLUB DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-298-9314
Tax Map No. section 109.00 block 3 lot 2.013
Cross Street
Issue Date: 10/01/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK Cj�FFU(4•" ii
Town of Southold . • ��/_
Application No.3
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Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road '111';1;14a $10.00 - Residential_
P. O. Box 1179 v' $25.00 - Non-Residential
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Southold, New York 11971 O d 'rr1j.V �`�
Telephone
(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: - b U �� b
OWNER MAILING ADDRESS: t ( c 1 D
Im® ' --y: -v,. J Pc)/ . !11
OWNER PROPERTY ADDRESTn
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OWNER TELEPHONE NUMBER: cI ,e — q$ l `I
TAX MAP NO. : Section / 0 q Block 3 Lot 02 713
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New 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.)
.- 411411111sellibb-
,Snature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: