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HomeMy WebLinkAboutKurkoski JUDITH T. TERRY :1C Town Hall, 53095 Main Road TOWN CLERK • T P.O. Box 1179 Southold, New York 11971 REGISTRAR OF VITAL STATISTICS ` �`� 516 MARRIAGE OFFICER (516) 765-1823 11 �® Fax'" Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1650-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner KURKOSKI, STANLEY Mailing Address 1 WICKHAM AVENUE Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 WICKHAM AVENUE Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 516-298-8188 Tax Map No. section 107.00 block ' lot 18.000 Cross Street MARY'S AVENUE Date Of Last Pump Out 0/00/80 Issue Date: 4/08/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) • OFFICE OF THE TOWN CLERK \ffO Town of Southold %c3— CQG Application No. /1� Judith T. Terry, Town Clerk ~ � Town Hall, 53095 Main Road `' $10.00 - Residential •C .�rhLF P. O. Box 1179 'f-© E � $25.00 - Non-Residential Southold, . New York 11971 OO �O�•�J Telephone j 4 (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. /® 7-- -/7' Fee $ Il34, .n/ DATE :7-.110279/ • OWNER NAME: , ,�: / , ✓ tet. .(1=:'1-'" " OWNER MAILING ADDRESS �/1 �h /rd J Al i7 iruc,V,( L, (, OWNER PROPERTY ADDRESS: r"c'`p_,,,„.0j„• OWNER TELEPHONE NUMBER: z4 ri (� TAX MAP NO. : Section Block Lot CROSS STREET: TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: n_1:2,(71 1 et/ / PQ / t I 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.) (--b-t,14141-.431? Signature of Applicant RECEIVED BY: Town Clerk's Office DATE: 1 . 1 if-%•-•:' & . i .... - , , . . I . . , I . . , . . , . . . . , . . I , . .,-------7-7-- .•- - - . , . i - . . . . . . , . , . . . . , , . . . . . . , . . . -.,--.--.. - H . . . . . . ,. . . , L____...._. ...... , . . . , , . ... 1. •' W fr . . . . ., 51 . - '..c". . ..... 11111111111 6 . ....._ u se. ...-.' 1 _ , .. . i . . . . . , " . , . . . , . . - , . . . , . . ... , . , • . . . . . . . . . . . •