HomeMy WebLinkAboutHusak 4000
Town Hall, 53095 Main Road
__ �;� P.O. Box 1179
� s2 '��� 0!� Southold, New York 11971
JUDITH T.TERRY ®- '`?=s , TELEPHONE
TOWN CLERIC (516)765-1801 -�
REGISTRAR OI VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 896-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner HUSAK, FRANK
Mailing Address 1 4400 LUTHERS ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4400 LUTHERS ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4669
Tax Map No. section 99.00 block 5 lot 3.000
Cross Street NAUGLES ROAD
Date Of Last Pump Out 0/00/84
Issue Date: 11/01/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK %c3\\FFO(,-`;• S
Town of Southold � Q Application No. 9�
Judith T. Terry, Town Clerk • ,�y
Town Hall, 53095 Main Road �,�.,: -� Residential
P. O. Box 1179 °4i Non-Residential
Southold, New York 11971 Cb„.
Telephone _ 4140
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. On
Fee $ / b, 66
DATE /° /cP /a
- OWNER NAME:
OWNER MAILING ADDRESS: y ! Q 0 I— U Q
7)'14 TT/ 7-° c- K
OWNER PROPERTY ADDRESS: Sal
OWNER TELEPHONE NUMBER: 9 6 f
TAX MAP NO. : Section q 9 Block Lot 3
CROSS STREET: )P16&(--e--3/(- (7
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool A/ New Existing
Residential i7V. Non-Residential
DATE OF PREVIOUS PUMP-OUT: �' f ,97
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.)
jt44-4%
Signature of Applicant
RECEIVED BY:
wn Clerk's Office
DATE: /64s/F6
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