HomeMy WebLinkAboutLipnicki OFFICE OF THE TOWN CLERK 6 cOFO[/(C,�
Town of Southold � . � cfa
Judith T. Terry, Town Clerk A ;rf
Town Hall, 53095 Main Road r £ z`,
P. O. Box 1179 Iti yc,,'
Southold, New York 11971 \
Telephone :7701
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No. 505 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Edward and Ann R. Lipnicki
OWNER MAILING ADDRESS: 1600 Alvahs Lane
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: 1600 Alvahs Lane
Cutchogue, New York •
OWNER TELEPHONE NUMBER: 516-734-6810
TAX MAP NO. : Section 102 Block 4 Lot 8
CROSS STREET: Main Road (Route 25)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: October 1984
Ju i ° . er
Southold Town erk
DATE: December 1, 1987
(TOWN SEAL)
ie
OFFICE OF THE TOWN CLERK C51F urpi)
Town of Southold , 0�® :'s CDl/ Application No. S
Judith T. Terry, Town Clerk Residential
Town Hall, 53095 Main Road _.. .
P. O. Box 1179tr3 .` Non-Residential
Southold New York 11971 � ®
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
For
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. v�5--
Fee $ ,U —
DATE / 1— D c
OWNER NAME: v 4- J G
OWNER MAILING ADDRESS: / 00 /9/ U2)6G7L-c_ 0 5 Lk. e_ r /) 9 3 .s
OWNER PROPERTY ADDRESS: � WI (=D-
OWNER TELEPHONE NUMBER: 7,5 9- C / ()
TAX MAP NO. : Section /0 A Block Lot •
CROSS STREET: 13 e' `17 tv ) -- -C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 0 / 21Y
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.)
ppp / /
()2C(7-
\ Signature of A. .li• nt
RECEIVED BY: Lim ���C
Town Clerk's fice
FICEIVED
DATE:
DEC 011987
Town C4erk Southold