HomeMy WebLinkAboutBanick OFFICE OF THE TOWN CLERK IRA';-
Town of Southold (0
Judith T. Terry, Town Clerk l
Town Hall, 53095 Main Road k t n �
P. O. Box 1179 �� ; tro:Southold New York 11971 ' 'e,. Nr
Telephone I Nip ,r
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. NR41 Residential
Fee $ 25.00 Non-Residential X
Septic Cesspool X
NAME OF OWNER: Agnes P. Banick
OWNER MAILING ADDRESS: Box 834
Southold, New York 11971
OWNER PROPERTY ADDRESS: 1235 Youngs Avenue
Southold, New York 11971
OWNER TELEPHONE NUMBER: 516-765-3231
TAX MAP NO. : Section 60 Block 2 Lot 4
CROSS STREET: Traveler Street
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential Non-Residential X
DATE OF PREVIOUS PUMP-OUT: March 1987
Judith T. Terry
Southold Town Clerk
DATE: • July 29, 1987 -
(TOWN SEAL)
� I
OFFICE OF THE TOWN CLERK•
Town of Southold Application No.
Judith T. Terry, Town Clerk .`
Town Hall, 53095 Main Road Residential
P. O. Box 1179 �' �•t. �-� �i .`' Non-Residential
k
Southold, New York 11971 -®
Telephone l Or°
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ,21/46",
DATE 7
OWNER NAME: A 62 !l( E3 p )3A 6y j C 6 1
OWNER MAILING ADDRESS: )36 ( 3
,YD p (1,0;. 1197(
OWNER PROPERTY ADDRESS: ) 33/ U/V 6,5 A a
,_'6 N Y 1 / Q7/
OWNER TELEPHONE NUMBER: �c .'-- 3 3 l
TAX MAP NO. : Section 6 6 Block g Lot vi
CROSS STREET: i/ AVgi- gi s ITHFE f
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing
Residential 'Non-Residential
--DATE OF PREVIOUS PUMP-OUT: _j/ ,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.)
4.-a-mte.4
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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