HomeMy WebLinkAboutFaszczewski 4"4-11�����WJ��R7y� -
Ill.
Town Hall, 53095 Main Road
� � P.O. Box 1179
' ./y,,/� Southold, New York 11971
JUDITH T.TERRYFAX FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1172-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FASZCZEWSKI, VIRGINIA
Mailing Address 1 BOX 378
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3608
Tax Map No. section 70.00 block 5 lot 1 .000
Cross Street JOCKEY CREEK DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 6/26/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
J I� Ii.
OFFICE OF THE TOWN CLERK ' ejutFO(A,
Town of Southold � ,_ C� Application No.
Judith T. Terry, Town Clerk `
K �,
Town Hall, 53095 Main Road 3 „k $10.00 - Residential
P. O. Box 1179 u' !• • $25.00 - Non-Residential
Southold, New York 11971 O ® fl*- 0���.
Telephone ( `A
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 6/�. /Fc
OWNER NAME: � t r-00U 1 fiAczu--)
s-k ,
•
OWNER MAILING ADDRESS: 60X 7�
$O
o-f-ho1- 7 ti 1 I1'7 1
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: X65_ �jLOO
TAX MAP NO. : Section ') 6 Block 5 Lot /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing \ A
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:SpA,,,1- ) 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.)
Signaure.�f�pplicant
RECEIVED BY:
Town Clerk's Office
Ftr 71V70.
DATE:
JUN 2 Iss9
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