HomeMy WebLinkAboutMalek OFFICE OF THE TOWN CLERK • •c)IFD((0;
Town of Southold
Judith T. Terry, Town Clerk0 �
Town Hall, 53095 Main Road
P. O. Box 1179 ir
Southold, New York 11971 O `� ®-� '
Telephone ' ,a.( ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 465 Residential x
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Viola Malek
OWNER MAILING ADDRESS: Box 62
Peconic, New York 11958
OWNER PROPERTY ADDRESS: Mill Lane
Peconic, New York
OWNER TELEPHONE NUMBER: 516-765-3187
TAX MAP NO. : Section 67 Block 5 Lot
CROSS STREET: Soundview Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
iclitfi Ty�ry
Southold Town Clerk
DATE: October 19, 1987
(TOWN SEAL)
Igo
OFFICE OF THE TOWN CLERK IS c.0Faiir = `_
Town of Southold CQG',, Application No. //��
Judith T. Terry, Town Clerk .� �
Town Hall, 53095 Main Road y � =4,
Residential ✓
P. O. Box 1179 .n J@ Pz Non-Residential
Southold, New York 11971 O ®, ��.
oe
Telephone �.(� %�
(516) . 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / DD
DATE Da f
OWNER NAME: VJoL ma LE
OWNER MAILING ADDRESS: BoX 6 - PEco%/iC
OWNER PROPERTY ADDRESS: MILL LANE Pec o ,V i c , Al l.
OWNER TELEPHONE NUMBER: 765--3187
TAX MAP NO. : Section 7 Block 5 Lot c 9
CROSS STREET: 90 t,4 l /e,14/ �✓, v P N q
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: SEP 2 - ç'7
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.)
l/ /•�%Com- �7 C�i���/�
Signature of Applicant
RECEIVED BY: 4 '
own/' ms's Office
DATE: 1✓*7 1