HomeMy WebLinkAboutHuzsek xprir4-**;70‘,N‘,
q,Pl� Town Hall, 53095 Main Road
/ P.O. Box 1179
lir€091, Southold, New York 11971
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JUDITH T.TERRY 11,`® = (5 TELEPHONE
TOWN CLERK
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. 3582-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner HUZSEK, ANDREW
Mailing Address 1 19 MADISON STREET
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 19 MADISON STREET
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-2136
Tax Map No. section 40.00 block 5 lot 19.000
Cross Street WILMARTH AVENUE/NORTH ROAD
Issue Date: 2/11/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �cvFFOC,r
Town of Southold �� c, k--..t..,
,, Application No. ,_
Judith T. Terry, Town Clerk ��� ,- y
Town Hall, 53095 Main Road -< $10.00 - Residential
P. O. Box 1179 v' ' , . - . $
Telephone
$25.00 - N_on-Residential
Southold, New York 11971 �'
Telephone N 0 o
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. v3-5.),Ra
Fee
$ /t.
DATE e-6 1)1 (q5-7
OWNER NAME: PrIn) I) R1�1,0 HUMS 6-k_
OWNER MAILING ADDRESS: 1 1 A4 A-61 Sort Si-
6-(2_ e►I) Pott- 1i N -1 61 Li-y-
OWNERER PROPERTY ADDRESS : S Pc-i'
OWNER TELEPHONE NUMBER: Si(i- q11--A15‘.
I/O - -� f 9
TAX MAP NO. : Section /-1-? 3 fel Block 4 0.---s-- (1 Lot
CROSS STREET: W i (tnarh PNe• — X10 vz- I N- km
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TYPE OF SYSTEM: Septic Tank New Existing `
'
Cesspool ✓ a New Existing ✓
Residential ir 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.)
a/iV/6162x/1--
Sigatureo Applicant
RECEIVED BY: �, ,��2
Town Clerk's Office
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DATE: 2/J D / 7
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