HomeMy WebLinkAboutKoloski JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK z T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS to 1 Southold, New York 11971
�✓ t Fax (516) 765-1823
MARRIAGE OFFICER
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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. 3140-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KOLOSKI, CHESTER
Mailing Address 1 2250 BEEBE DRIVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2250 BEEBE DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6793
Tax Map No. section 103.00 block 3 lot 9.000
Cross Street FAWN LANE
Date Of Last Pump Out 0/00/00
Issue Date: 11/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •c.31FO(A."
Town of Southold �� ,:- CQG' Application No. 3
Judith T. Terry, Town Clerk - tit
Town Hall, 53095 Main Road . $10.00 - Residential
p. O. Box 1179 cr3 n` tri ; $25.00 - Non-Residential
Southold, New York 11971 O _ �•
Telephone,('
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL •
Operation Permit No.. /4/,
Fee $ )G;•
DATE 140—
OWNER NAME: a S%,e .i- 1-6)
OWNER MAILING ADDRESS: ,2625-0 fir e_
;,r•y . 1193s-
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• OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: / .3 / – 7 93
TAX MAP NO. : Section /o j Block 5 Lot
CROSS STREET: � �
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool f New Existing
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: cj)/ 9 3
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
RECEIVED BY: AL/ /
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Town Clerk's Office
DATE: /G g6 _9
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