HomeMy WebLinkAboutDoroski, Gerald SVFOUr
ELIZABETH A. NEVILLE 14I y� Town Hall, 53095 Main Road
TOWN CLERK ; o P.O. Box 1179
Z Southold, New York 11971
REGISTRAR OF VITAL STATISTICS 0
MARRIAGE OFFICER �� .fi �� ', Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER =_ l � ,°� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER � '�
OFFICE OF THE TOWN CLERK
SOUTHOLDITC/PsTzEIRIIIMIRQSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4116-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner DOROSKI, GERALD M & MELANIE
Mailing Address 1 65 AUGUST LANE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 65 AUGUST LANE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 631-11.77-1835
Tax Map No. section 53.00 block 4 lot 44.013
Cross Street KERWIN STREET
a� r,
Issue Date: 12/24/01 E abeth A. Neville
Southold Town Clerk
(TOWN SEAL)
00 se
OF THE
OWN
O1FIR OWNOFSOTUTHOLDERK ��S�FFU(,{�`pG Application No. V//6
ELIZABETH A.NEVII.I.F,TOWN CLERK
$10.00 - Residential
P.O.BOX 1179
$25.00 - Non-Residential
SOUTHOLD,NEW YORK 11971 *.$
Telephone *el Jigt Ng '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2177R
Fee $
DATE 'r 11/01
OWNER NAME: DOROSKI, GERALD M. & MELANIE
OWNER MAILING ADDRESS: 65 AUGUST LANE
GREENPORT, NY 11944
OWNER PROPERTY ADDRESS: 65 AUGUST LANE
GREENPORT, NY 11944
OWNER TELEPHONE NUMBER: 631-477-1835
TAX MAP NO. : Section 53.00 Block 4 Lot 44.013
CROSS STREET: KERWIN BLVD
TYPE OF SYSTEM: Septic Tank X New x Existing
Cesspool X New X Existing
Residential X 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.)
Signat of Applicant
RECEIVED BY: /16///---X--)?----74___
y/l7A/4
Town Clerk's Offi
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DATE:
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AN r AL TERA TIO OR ADDi TION TC THIS SURVE r iS 4 VTOL 4 TiON 3G
OF SECT/ON 7209 OF THE NEw r0RK STATE EDUCATION _.4vW A
EXCEPT AS PER SECTION 7209-SUEDI vI SION 2 ALL ('EP T IFrCA TION_;
HEREON ARE VALID FOR TH%S MAP AND COPIES THEREOF ONL r 'F
SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SuPVE rOR
WHOSE SIGNATURE APPEARS HEREON.