HomeMy WebLinkAboutLolic t
`riI
w 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. 1569-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LOLIC, MLADEN J.
Mailing Address 1 141-10 NEGUNDO AVENUE
Mailing Address 2
City St Zip FLUSHING NY 01135-0000
Property Address 1 140 PINE AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 718-225-5019
Tax Map No. section 77.00 block 3 lot 13.001
Cross Street HICKORY AVENUE
Date Of Last Pump Out 0/00/00"
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK VFD(A"' C
-- Town of Southold �� ; CQG•` Application No. 1,7f
Judith T. Terry, Town Clerk -:fs` h �': •� $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 cry t --,- *► $25.00 - Non-Residential
Southold, New York 11971Ar ••`
Telephone _(I.( �t�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /bpi�v
'OWNER NAME: , ' `/q)Iil d L 04 / c '
OWNER MAILING ADDRESS: /Lf/—/G /A/E6G//)7 O , 4/4-7,
fi z- S g/ ( /l/
OWNER PROPERTY ADDRESS: /40 Pzivt it"F,
S'®'7HOLD A //?7/
OWNER TELEPHONE NUMBER: ' Cm) 2250f?
TAX MAP NO. : Section 77 Block 3 Lot 13,
CROSS STREET: H//C/ o4L/f
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 distance, approximately, to building and closest road.)
Signature of pplicant - -
RECEIVED BY:
Town Clerk's Office -
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