HomeMy WebLinkAboutDoroski (2) /'�F
� ���
ELIZABETH A.NEVILLETown Hall, 53095 Main Road
'°
Wit r P.O. Box 1179
TOWN CLERK 1 ® b„<,F , .�,: va
REGISTRAR OF VITAL STATISTICS 747 � Southold,New York 11971
® ' � Fax(516) 765-1823
MARRIAGE OFFICER � ��®���� Telephone(516) 765-1800
RECORDS MANAGEMENT OFFICER �e
FREEDOM OF INFORMATION OFFICER 4 .I.'�I
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3791-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DOROSKI, JOHN C.
Mailing Address 1 3000 PEQUASH AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 3000 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6788
Tax Map No. section 103.00 block 13 lot 24.000
Cross Street WEST CREEK ROAD
Issue Date: 5/20/98 Elizabeth A. Ne 11 e
Southold Town Clerk
(TOWN SEAL)
OFFICE'OF THE TOWN CLERK
TOWNOFSOUTHOLD S
� COG Appli-cation No. -29/
t-N ,----
ELIZABETH A.NEVILLE;TOWN CLERK G $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEWYORK 11971 ) 1,�� $25.00 - Non-Residential
• Telephone - _O1 * 0:"
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DAT j f /( 1
OWNER NAME: -, 4._
119,,,,..,e61
/
OWNER MAILINJADDRESS: S® p 0 ,, 40..b_P_
' '. .,.,,e_ . y . n.gO
OWNER PROPERTY ADDRESS: gB 40 , ,,__, •-e_.> 11
r f /, _ _ , . //q36
OWNER TELEPHONE NUMBER: 7',361 — ‘7 p e
TAX MAP NO. : Section -: >-- Block / Lot Z--',,,ZX
CROSS STREET: y,: s,•��=�- i411V , . ,4_ 'P,
TYPE. OF SYSTEM: Septic Tank New Existing Vedi
Cesspool New Existing f
Residential j/ 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.)
id. ' ,I;t-242;1‘f-;-:—
/../., �✓
Signature of • pplicant
RECEIVED BY: -LO " --
1)1 - _
Town
-
Town Clerk's Office
DATE: 7/0 9
i
i
ii 20 ;A
A
1 \ .
'IP
1 „
i-1- 0°
c-• ,
:___--- -
( tA-JP41
I), -
ii \,
p .
L----\ ,
_i
ti )
.,I1 - bil'''S'
pc- 5 ' 4,