HomeMy WebLinkAboutFetzko JUDITH T. TERRY G�t Town Hall, 53095 Main Road
TOWN CLERK ® �y P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MI
MARRIAGE OFFICER ®`�/® �4
y�` Fax (516) 765-1823
/ Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1890-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FETZKO, CAROLINE
Mailing Address 1 P. O. BOX 499
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1120 SIGSBEE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8348
Tax Map No. section 144.00 block 1 lot 3.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 4/24/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OI FICE OF THE TOWN CLERK ��jvFF�(�•�'= '_
Town of Southold �� ,: CQ Application No. /?2
Judith T. Terry, Town Clerk "E ' �`�
Town Hall, 53095 Main' Road '�;� :'� $10.00 - Residential V
P. 0. Box 1179 u' ; "
. $25.00 - Non-Residential
Southold, New York 11971 O �'`e -• S
Telephone _ .(
rod
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ,i/k/ 1/
OWNER NAME: (7/Q.-00 fro
OWNER MAILING ADDRESS: %d6 X 47/
/(-1 -7---7--/' 7V (_/ N y //
OWNER PROPERTY ADDRESS : /t,20 � he„, /1
/i` /JG/C (Y)
/
OWNER TELEPHONE NUMBER: -� q ) - s›,(-)
TAX MAP NO. : Section /VL/ Block— / Lot
• CROSS STREET: %27r 2` v'7/9
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - New Existing,
Residential J Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6/97
LOCATION MAP: Must be attached hereto re permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
deede-re_ej
Signature of Ap icant
RECEIVED BY: 4'`--x��U-
erks 0 fice
DATE: APR 24. 199)
Iowa Clerk Southold
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