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HomeMy WebLinkAboutRoslak JUDITH T. TERRY w Town Hall, 53095 Main Road TOWN CLERK , 2:t7.7, 3 1 P.O. Box 1 179 REGISTRAR OF VITAL STATISTICS y<«; \, Southold, New York 11971 MARRIAGE OFFICER ^ • '. ;'Y Fax (516) 765-1823 Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 1615-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New X Existing Name Of Owner ROSLAK, JOHN AND MAUREEN Mailing Address 1 40 ORIOLE DRIVE Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address 1 40 ORIOLE DRIVE Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-765-4611 Tax' Map No. section 55.00 block 6 lot 15.001 Cross Street TUTHILL ROAD EXTENSION Date Of Last Pump Out 0/00/00 Issue Date: 1/17/91 Judith T. Terry Southold Town Clerk (TOWN SEAL) CI�-FiCE OF THE TOWN CLERK �S�FFD(,��'- Town of Southold QICSG•, Application No. / !D) Judith T. Terry, Town Clerk a 4 ,s . $10.00 - Residential Town Hall, 53095 Main Road � �� �;'-�_ �YK lein4-r^�Y, p, 0. Box 1179 u-9 � `°= 4i ` $25.00 - Non-Residential Southold, New York 11971 O ®s ,; •0-0°.�`� Telephone -1 41( ,• R©go Vq (516) 765-1801 $ TOWN OF SOUTHOLD uiggo ; 7OE�t/ �hvCJS CSPT SOUTHOLD WASTEWATER DISPOSAL DISTRICT �r1¢.�4� APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ 10. 00 DATE 12/27/90 'OWNER NAME: John & Maureen Roslak • • OWNER MAILING ADDRESS: 40 Oriole Drive Southold, NY OWNER PROPERTY ADDRESS: Same OWNER TELEPHONE NUMBER: (516) 765-4611 TAX MAP NO. : Section 55. 00 Block 6 Lot No 15. 1 CROSS STREET: Tuthill Road Extension TYPE OF SYSTEM: Septic Tank Pre-Cast New XX Existing Cesspool Pre-Cast New XX Existing Residential XX Non-Residential DATE OF PREVIOUS PUMP-OUT: 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.) 40126 e /I Signa ure of Ap,.Iicant • RECEIVED BY: Town Clerk's Office DATE: J `4. r-Ti \ / 8/7- 0 L-- 12 b(7.--