HomeMy WebLinkAboutJackowski •
OFFICE OFTHETOWN CLERK ic,Of
Town of Southold N® ANI (GL
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
New York 11971 _� �
Southold,
Telephone ®.I c_
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 230 Residential x
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Irene D. Jackowski
OWNER MAILING ADDRESS: RFD 1 , Box 184, Pat Lane
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: Pat Lane
Mattituck, New YOrk
OWNER TELEPHONE NUMBER: 516-298-4047
TAX MAP NO. : Section 114 Block • 10 Lot
CROSS STREET: Mark Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 1986
• •
r
it erre
Southold Town erk
DATE: February 24, 1987
(TOWN SEAL)
�c ,'U''-= 73v
OFFICE OF THE TOWN CLERK PFFD -
Town of Southold &% l',' . Application No.
Judith T. Terry, Town Clerk ‘ x,„--:.: 'icf r 1
ter" Residential
Town Hall, 53095 Main Road c * €" , -
P. 0. Box 1179 cn .1,76. MO `' Non-Residential
Southold, New York 11971 O`® :' ��
�
Telephone r.( ����
(516) 765-1801
TOWN OF SOUTHOLD -
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. O (3C)
Fee $ 4,.
DATE 4A31?
OWNER NAME: —/i ce (0,cdr�'iec e/ •/
OWNER MAILING ADDRESS: A:0,w/�e, /6 9Z,�
�i¢r1"ie.>7/ A/71 //i$—
OWNER PROPERTY ADDRESS:
' ,--3141
OWNER TELEPHONE NUMBER: a��- 7147
TAX MAP NO. : Section /1 Block /® Lot o
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing A--
Residential
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ` 4..(4y �‘'
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.)
Ems..:==
-/tic' '�
- "y �
' '. -%-_ � ,.�T''�' • -�i.--�...
Le_ /�%Y%
Sign/ure of Applicant
RECEIVED BY: x-&-c,_Gt.� ee-r �le,v
,,,, £v�T�own lerk's Office
DATE: FFR 24 1987
town Clerk Southold
4 �
35 2
S
•
ZREN UkISE/
?1q-Yl/77i9P Adm,
SEGTJDAI /
LD UC .1 17
IDT
A1fJR7'�J
F . 23v_e J9d7