HomeMy WebLinkAboutJurzenia OFFICE OF THE TOWN CLERK 4 F[1
Town of Southold ' 0����F �C��Judith T. Terry, Town Clerk .s.. ..
Town Hall, 53095/Main Road
P. O. Box 1179 . �`
Southold, New York 11971 \\ '�. �0�-t•�
Telephone - �l
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 513 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Florence Jurzenia
OWNER MAILING ADDRESS: Silvermere Road
Greenport, New YOrk 11944
OWNER PROPERTY ADDRESS: Silvermere Road
Greenport, New York
OWNER TELEPHONE NUMBER: 516-477-0011
TAX MAP NO. : Section 47 Block 2 Lot • 12
CROSS STREET:
Shore Drive
TYPE OF SYSTEM: Septic Tank , • New Existing
Cesspool X New Existing' X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
joi rs if ;4,7,4,03,
Judith T. Terry
Southold Town Clerk
DATE: December 3, 1987
(TOWN SEAL)
• ".
OFFICE OF THE TOWN CLERK �c�vFFO(,-e'` _
Town of Southold �� Application No.-573
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%Judith T. Terry, Town Clerk % , -- e"-----
Town
�
Town Hall, 53095 Main Road ;; ,...-,,--.. ..1I Residential
�
P. O. Box 1179 �' 4.4 = � ; . Non-Residential
Southold, New York 11971 O ^ 0 $
Telephone ( '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /2 .0 ? Y-7
. ZOA 71/CE 1/4e74-4//79
OWNER NAME: ,
OWNER MAILING ADDRESS: 1zge-x ®�6 .�
Q�4- -Aliooer j A/y //ye3i
OWNER PROPERTY ADDRESS: ..5--/ 72 E
OWNER TELEPHONE NUMBER: 1y7-- Pd J1'
TAX MAP NO. : Section 117 Block a-- Lot /)-
CROSS STREET: ' 'j}i .
TYPE OF SYSTEM: Septic Tank New Existing '
Cesspool V New Existing I/
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
(0-b_h 4, / , _
Signature of a pplicant
RECEIVEDC6
KIggbTown CleMs Offi
DATE: DEC 03 P%?
Town Clerk Southold
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