HomeMy WebLinkAboutJablonski OFFICE OF THE TOWN CLERK
Town of Southold ,� 0�� CDG
Judith T. Terry, Town Clerk Z`
Town Hall, 53095 Main,Road a
P. O. Box 1179
Southold, New York 11971 _40 i•
;
Telephone ( * Y► '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 51 Residential xx
Non-Residential
Fee $ 10.00
Septic Cesspool xx
NAME OF OWNER: Chester and Anne Jablonski
OWNER MAILING ADDRESS: P.O. Box 254
Cutchogue, New York 11935
--OWNER -PROPER I'Y --ADDRESS-: ---Ma-in-Road
Cutchogue, New York
OWNER TELEPHONE NUMBER: 516-734-6402
TAX MAP NO. : Section 109 Block 3 Lot 3
CROSS STREET: Alvah Lane -
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool xx New Existing XX
Residential xx Non-Residential
DATE OF PREVIOUS PUMP-OUT: August 1986
ucntYl'T. rry,�
Southold Town CIffk
DATE: September 19. 1986
(TOWN SEAL)
La r' „
OFFICE OF THE TOWN CLERK �FF�O'
Town of Southold ��� - ' CO� Application No. 5-4,
Judith T. Terry, Town Clerk % , x., p �► .
Town Hall, 53095 Main Road c :'� } Residential
*1i
a
P. 0. Box 1179 00to14,: ' ► � Non-Residential
Southold, New York 11971 ,4r...•
(516)
Telephone ..
(516) 765-1801 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. S- -/
Fee $ JO
DATE V/Q/ ./%
OWNER NAME:
v
OWNER MAILING ADDRESS: `-M GL z J ' ) 8. 0781°
OWNER PROPERTY ;'-ADDRESS: — o «
OWNER TELEPHONE NUMBER: 1 3 —640
TAX MAP NO. : Section/6 9 Block 3 Lot
(}I I
CROSS STREET: �i1 iLG
i
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool c/ New Existing Ly
ResidentialNon-Residential
DATE OF PREVIOUS PUMP-OUT: J ,re)-- f, r pc
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.)
ignature of Applicant
RECEIVED BY: : I_ C J
Town ferk's 0 fice
DATE: ' ' /9, /99
_,
s
_________
fi
/1 e
CCp } 1
416
, n /
1
i i