HomeMy WebLinkAboutBlaschack OFFICE OF THE TOWN CLERK
Town of Southold ii"
Judith T. Terry, Town Clerk �
Town Hall, 53095 Main Road o Y�h , '4h
P. O. Box 1179 trl "r#4
Southold, New York 11971 tt,91x,
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Telephone AEA
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. NR45 Residential
Fee $ 25.00 Non-Residential X
Septic Cesspool X
NAME OF OWNER: Alexander Blaschack - Blaschack Rest Home
OWNER MAILING ADDRESS: 555 New Suffolk Road
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: 555 New Suffolk Road
Cutchogue, New York
OWNER TELEPHONE NUMBER: 516-734-5959
TAX MAP NO. : Section 102 Block 6 Lot 9
CROSS STREET: Route 25
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential Non-Residential X
DATE OF PREVIOUS PUMP-OUT: Pool is pumped every three months
Judith T. Terry
Southold Town Clerk
DATE: July 29, 1987 _
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �� F irp-- f
Town of Southold -,,,-,a1- Qom'_, Application No. 4 ei5
Judith T. Terry, Town Clerk
Off, x
� �• '�:� •� •I Residential
Town Hall, 53095 ,Main Road c .; i
P. O. Box 1179 cn f4' •' Mi a' `on-Residential
Southold, New York 11971 O z -
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Tel _ .( 4 �, •
(516) 765-1801 At)i)11;)
TOWN OF SOUTHOLD 1
SOUTHOLD WASTEWATER DISPOSAL DISTRICT `‘t,Iiii" 4 \y‘i 9/
APPLICATION
for' .\\\ /‘: f<N\ , Ili
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OPERATION PERMIT N I"
SEPTIC TANK or CESSPOOL ell
O eration Permit No.
Fee /0.-'-
(._ 0•-'- a(5": i , .. (-\\6 t.1
DATE 7//PA9
OWNER NAME: '6) j2_ �R a-4- 4*-Q 0L I&Sal. -.
OWNER MAILING ADDRESS: S—"-- NI-..6 U `` ' -
OWNER PROPERTY ADDRESS: SI--1•0-,.--
OWNER
6-y0-.OWNER TELEPHONE NUMBER: f) J(:)--- - 5-i a
TAX MAP NO. : Section j0 2, Block 6 Lot c
CROSS STREET: $(3.)-4 c ` C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1( New Existing
Residential Non-Residential
- DATE OF PREVIOUS PUMP-OUT: . 'I ,- / . _ 0 ...,c._., /
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.)
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Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
NOTE: Please be advised that the fee for the rest home (not a private dwelling)
is $25.00.
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