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HomeMy WebLinkAboutRoslak I 4,..., „"...., ,,,,fuLt , , , 6m t �c' Town Hall, 53095 Main Road �. P.O. Box 1179 $ 0 Southold, New York 11971 JUDITH T.TERRY „.ii./040 TELEPHONE TOWN CLERK (516)765-1801 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. 724-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner ROSLAK, THOMAS J. & LOIS J. Mailing Address 1 P. O. BOX 164 Mailing Address 2 City St Zip CUTCHOGUE NY 11935-0000 Property Address 1 765 TRACK AVENUE Property Address 2 City St Zip CUTCHOGUE NY 11935-0000 Owner Telephone No. 516-734-5270 Tax Map No. section 137.00 block 1 lot 23 . 000 Cross Street STILLWATER AVENUE Date Of Last Pump Out 0/00/80 Issue Date: 6/03/88 Judith T. Terry Southold Town Clerk (TOWN SEAL) OEI ICE OF THE TOWN CLERK i�OFp(A' Town of Southold �� CQ ' , Application No:7d5i Judith T. Terry, Town Clerk 44 � a Town Hall, 53095 Main Road ,,et ;� . ''� Residential P. 0• Box 1179 ‘,"- 11(Z/• � ,_ ' �' Non-Residential Southold, New York 11971 O �' Telephone ' 0.(�R ‘1 ;.� (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ /© DATE Ic i ��► d OWNER NAME: 7 , z9-S J 5 Y eS• J . RSLAk OWNER MAILING ADDRESS:(-, D , J C " 04-i)r-c-k c , Nee-4' d pie 119-rJ— OWNER PROPERTY ADDRESS: 7&5— C6 IA 5 GtL /Ue-c-' �n./C i r 9Ism OWNER TELEPHONE NUMBER: (S/G' 73 Z 7O TAX MAP NO. : Section /j 7 Block / Lot 7s- CROSS STREET: �� �! tee, 2 _t , TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing 7& Residential I/ 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.) Signat e of Applicant RECEIVED BY: Gwlcau-- Town (Clerk's ffice REM 0) DATE: • JUN 0 3 1988 Town Clerk Southold , °b�