HomeMy WebLinkAboutKolaczyk 11, •-' .
JUDITH T. TERRYTown Hall, 53095 Main Road
TOWN CLERK ® �� P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
®��® � �l� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3052-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KOLACZYK, CHESTER AND MARION
Mailing Address 1 10 JAYNE AVENUE
Mailing Address 2
City St Zip MELVILLE NY 11747-0000
Property Address 1 1930 BRAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-427-7757
Tax Map No. section 126.00 block 7 lot 21 .000
Cross Street THIRD STREET
Date Of Last Pump Out 0/00/00
Issue Date: 6/28/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERKVFFU
Town of Southold ��� �CQ ' Application No. c3a5°2-d
Judith T. Terry, Town Clerk i��
Town Hall, 53095 Main- Road -.4 $10.00 - Residential
o �4 �x ��
P. O. Box 1179 u' w Q ' . $25.00 - Non-Residential
Southold, New York 11971 O*0'4-
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Telephone ( Y► •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O.1 "
DATE 6 - 0,,02 -93
OWNER NAME: e Es77 V"14.4?CO/t/ ,OL.4cZyK
OWNER MAILING ADDRESS: /p 371'+°°jl/E - VEAlJE
M TL.LE /t/ / /17V7
OWNER- PROPERTY ADDRESS: /930 8 42A y 4--vExfOE
M A i T/MO( d, /�Q5
OWNER TELEPHONE NUMBER: (S'/( )
TAX MAP NO. : Section 1,A6, Block 7 Lot
' CROSS STREET: 7-4/ 4 5?Y et
T•YPE"•;OF;SYSTEM: Septic Tank `'= - New Existing
Cesspool V New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: i/ 4 fi v-tor O
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.)
/ / 10=` f �.
Signature of Applicant
RECEIVED BY,; ;> - — - - -
Town Clerk's Office
DATE: - -
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