HomeMy WebLinkAboutDoroski i
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i Town Hall, 53095 Main Road
_ 7 �`� P.O. Box 1179
: . � ,/� Southold, New York 11971
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F 000 FAX
FAX(516)765-1823
JUDITH T.TERRY .-.-,,,,ii
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1260-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DOROSKI, JOHN S. AND MARY
Mailing Address 1 16 MIDDLETON ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 16 MIDDLETON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1204
Tax Map No. section 40.00 block 5 lot 15.000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/74
Issue Date: 10/11/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c��FFO(,-C'-= Application No. KJ l�l(�
Town of Southold � �
Judith T. Terry, Town Clerk .*,:�►
Town.' Hal:; 53095 Main Road _ r,i ,, : =4 $10.00 - Residential
P. O. Box 1179 u-3 . •
� ;� �#j�y,�s �• $25.00 - Non-Residential
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Southold, New York 11971 `c
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Telephone �j y N • •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION P-ERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /10 , (
DATE �Q c // / 9
OWNER NAME:
OWNER MAILING DDRESS: oecio
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OWNER PROPERTY ADDRESS: 15 ,E
OWNER TELEPHONE NUMBER: /' '- 1/77 %a D 17(
TAX MAP NO. : Section 6.--/D Block , � Lot
CROSS STREET: Taw
TYPE OF SYSTEM: Septic Tank - New Existing / 9L/
Cesspool 1 R..� New Existing / 9-// '-
Residential l Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 7 7
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.)
...9L A 9
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Signature of Applicant
RECEIVED BY: 1 "Th
"o n Clerk's Office
DATE: /U /1 >?7
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