HomeMy WebLinkAboutKirincic OFFICE OF THE TOWN CLERK 6 COFU[frC,
Town of Southold � ��
Judith T. Terry, Town Clerk ,t k .
Town Hall, 53095 Main Road o �.
P. 0. Box 1179 �, '' `` =r-n :
Southold, New York 11971 = �
Telephone j®.,\`O"'O( 1*0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 503 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Nick Kirincic
OWNER MAILING ADDRESS: 975 Tuckers Lane
Southold, New York 11971
OWNER PROPERTY ADDRESS: 975 Tuckers Lane_
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-1819
TAX MAP NO. : Section 59 - Block 10 Lot 13
CROSS STREET: Main Road (Rt. 25)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1986
Judith T. Terry
Southold Town Clerk
DATE: December 1, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cOFO(,(
Town of Southold CQ ' Application No. _rjQ
Judith T. Terry, Town Clerk .` " v y --
Town Hall, 53095 Main Road . :'� } Residential
(l ee"� �"
P. O. Box 1179 cry sNon-Residential
Southold, New York 11971 O � r'a4A\`c-•
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit tNo.L.6103
Fee $ /0000
DATE l/4---•
OWNER NAME: PI I GK
OWNER MAILING ADDRESS: 7? s-
OWNER PROPERTY ADDRESS: ,7s-- C, U / U r
OWNER TELEPHONE NUMBER: 7‘;',S-----W7 '
TAX MAP NO. : Section Block Lot
CROSS STREET: A,-{,v ge77, 0 /?,
TYPE OF SYSTEM: Septic Tank ,New Existing 1../#7
Cesspool / New Existing
V Residential � Non-Residential
DATE OF PREVIOUS PUMP-OUT: 5UAj t--- _
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.)
Signature of Applicant
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RECEIVED BY: A •;, '
.wn rerki: Office
DATE: fi /ZU V
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