HomeMy WebLinkAboutJaworecki OFFICE OF THE TOWN CLERK ' •��FFU
Town of Southold � �C�G
Judith T. Terry, Town Clerk r E _
Town Hall, 53095 Main Road 1
P. 0. Box 1179
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Southold, New York 11971
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Telephone -' ,rac
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 48 Residential XX
Non-Residential
Fee $ 10.00
Septic Cesspool xx
NAME OF OWNER: Joseph Jaworecki
OWNER MAILING ADDRESS: P.O. Box 41
Orient, New York 11957
OWNER PROPERTY ADDRESS: 25 Youngs Road
Orient, New York
_ OWNER TELEPHONE NUMBER: 516-323-2541
TAX MAP NO. : Section 18 Block 2 Lot 20.1
CROSS STREET: Main Road (Route 25)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool xx New Existing XX
Residential xx Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 1986
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Judith T. Terr
Southold Town Clerk
DATE: September 18, 1986
'(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c5T4fi if.C• l/r
Town of Southold �� Q7G' Application No. _
Judith T. Terry, Town Clerk '
I Residential
Town Hall, 53095 Main Road
P. O. Box 1179 r„..';VIOA
. Non-Residential
Southold, New York 11971 1. t` '
TelephoneOl”igt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
i
Fee $
DATE Seri-, 17 f 191
OWNER NAME: JdSe f by .lq LA, d
OWNER MAILING ADDRESS: o25 c9 VIA S /O,A
O R ! e WT ICY II
OWNER PROPERTY ADDRESS: c:,)76— /() / j3•
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section / g Block Lot COs 9
CROSS STREET: f)')04,_5., ,6-/ ,a,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing ?
Residential . Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto efore permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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Si.rature opplicant
RECEIVED BY: y , .�-c J
Town CI kis Office
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