HomeMy WebLinkAboutKubacki Town Hall, 53095 Main Road
P.O. Box 1179
1 Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1264-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KUBACKI, JOSEPH AND DOROTHY
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Mailing Address 1 1980 NAKOMIS ROAD
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 1980 NAKOMIS ROAD
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000-
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Owner Telephone No. 516-765-4076
Tax Map No. section 87.00 block 1 lot 24.002
Cross Street WABASO ROAD
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Date Of Last Pump Out 0/00/00
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Issue Date: 10/11/89 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK S�Fr"7(/� '
Town of SoutholdO�� CDS - Application No.
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road -� $10.00 Residential
P. 0. Box 1179 cn $25.00 - Non-Residential
Southold, New York 11971 O
Telephone0,(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE11647
OWNER NAME: :n O a /� /qc
OWNER MAILING ADDRESS: eo rig I(z W"
OWNER PROPERTY ADDRESS: (? $40 dA"tV1,5 ,RD _
OWNER TELEPHONE NUMBER: --"/ 6
TAX MAP NO. : Section Block Lot 2, �-
CROSS STREET: 0&8&5:7��TJ
TYPE OF SYSTEM: Septic Tank New Existing
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 di tance, approximately, to building and closest road.)
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,Iyae_e�11�zlzc
_V jVgnature of Applicant
RECEIVED BY: c�c,� 4��
TT�own Clerk's-/Office
DATE: OCT! 0 1989
Tom Clerk Souttrouo
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