HomeMy WebLinkAboutKonarski Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY . ��I' FAX(516)765-1823
" ����� TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1169-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KONARSKI, SOPHIE
Mailing Address 1 NORTH ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 NORTH ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-3757
Tax Map No. section 74.00 block 3 lot 3.000
Cross Street CAROLE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/23/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 1cOW
Town of Southold A. � - CSG Application No.
Judith T. Terry, Town Clerk . , A -z- �`
=fid %) $10.00 - Residential
Town Hall, 53095 Main Road .,.,-,;,.4t -
P. O. Box 1179 u3 r>tWi % $25.00 - Non-Residential
Southold, New York 11971 O ' *V{ .$
Telephone .( yi '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. / / 7
Fee $ /,'2 O
. DATE Tune_ , s3 Mci
i
OWNER NAME: •
•
OWNER MAILING ADDRESS: 1\104-1-. ROQc ,
`Pe_c..4r c n.0. \V5 ?'
OWNER PROPERTY ADDRESS: @ctivve_.)
OWNER TELEPHONE NUMBER: 7( 5- j757
TAX MAP NO. : Section Li Block 3 Lot 3
CROSS STREET: 0,Oft e 1O&1
TYPE OF SYSTEM: Septic Tank New Existin 1/
Cesspool New Existing
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.)
/ I( //20_7 _a,a,
, /'
/ Signature of Applicant
RECEIVED BY: _�I . .
:/, � i,�,/_'/
erk s Q`ffice
DATE: 6/94---� 17
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