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HomeMy WebLinkAboutRuskiewicz 40- qgf ULArc -� , JUDITH T. TERRY Town Hall, 53095 Main Road TOWN CLERK f+ P.O. Box 1179 REGISTRAR OF VITAL STATISTICS Southold, New York 11971 MARRIAGE OFFICER ~ �® '��. 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. 1939-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner RUSKIEWICZ, WALTER Mailing Address 1 5 CURTIS PLACE Mailing Address 2 City St Zip LYNBROOK NY 11563-0000 Property Address 1 1350 RAMBLER ROAD Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-887-9398 Tax Map No. section 88.00 block 5 lot 15.000 Cross Street PLEASANT PLACE Date Of Last Pump Out 0/00/00 Issue Date: 6/26/92 Judith T. Terry Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK ocl \VF0(,(�`= Town of Southold A Application No. /Y3 Judith T. Terry, Town Clerk �`o r f Town Hall, 53095 Main Road 1A,,•f t-„ - I $10.00 - Residential p. O. Box 1179 cn }� ; $25.00 - Non-Residential Southold, New York 11971 O -® ;` ��jj�fii 0Telephone � 40% • (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ ©`) DATE ./�°--'// Z- • OWNER NAME: 1.0°Apus OWNER MAILING ADDRESS: 5' C J/2---rt $ ,OLfrC figs K ti // `3 OWNER PROPERTY-ADDRESS: i3$' 0 „tb- OWNER TELEPHONE NUMBER: '/1 -�� �J 5 3 7 T, TAX MAP NO. : Section Block 5 Lot 7� CROSS STREET: .Pc.e r-A-5- 17-- TYPE OF -SYSTEM: Septic Tank New Existing Cesspool ✓ New Existing ✓ Residential ✓` Non-Residential DATE OF PREVIOUS PUMP-OUT: LOCATION MAP: Must be attached hereto before permit may be issued. (Locate building and system; give north arrow and feet of distance, approximately, to building and closest road.) 04) Z/Z/ Signature of Applicant RECEIVED'BY: Zr ' - Town Cle k's Office DATE: RECD - - - 1 JUN 2 6199? Too Clerk S.outliofc 0 - 1.4 r f'' _ - 4 tRV' _ _ _ t'- _ _ • •cti••tr ..• - - _ - _ �� �p�" �'•Tw._• __ • - __ {,._ r - .. � _ _ - :�-�_ r^Y Vis•' - - i moi+!• ► - _ _ -_ ,� ,,--._45_,„:: fir- f • • -- _ - �Ey�yi - - - - �E�..-+ am-; _` i��' �_ ~ ^"' - • - - - ---7-!=-,-2.- - - - - - - • - :-k-4.:wi._.3.pig yam:_ -.P•' _ _ - Y - _ - - - 'Qkr� � - 1 r _itL(� :,.:._,= :,_0-_ - 4J. - _ - - - - - • �. - w t ;.-0 . } 3 � _ 1 i 1 s•s•-ill +' _ , _: .. • t c - \\ R•T'i"ORUME1 a a r ' 4 t. jam} { , \ - .. -xi- - _. i, _ - . - .,..... . , ., _ _ . _ , ,. . . .., \ _ - - '',_'-';.,.%% _ _ _ 1 • _ _ 4. - j+AIAUTMOR i1 'r - - 6 - ` �`- I SURVEY 15 A VIOLATION OF Y -w _ E- _ i - I• _- = SECTIOs172D9 OF T►1E NEW YOiK STATE _ = _ _ EDUCATION LAW. _ _ a.`:�.,• i i :r` om �'� + ed�1`�1 RS_ C�'' 4'$_ S�I ��ES OF T}11SSURVEY AIM-HOT IEA!{NG. :r _ _ _ -.......,.-„,„.......1—.----.7.-----7v-_-7 i._':.-• v _ d -''-'77,;:-:-.:1"-..1:-:.11'"•-•''-.":-;-'4. _ Y`t_ i lM1USSED SEAL SHALL NOT E C _ Y'__ f, rr•'_ t 1_ _ __ __ 7_��T��' rte, _-yi r' ``.�f .----1.,2,,,,.„,"-:- ..f } - +4- - _ - .L`f•- :C_ i"� - _ k _ _ _ } - 1 O pE'A YAL �' UE_COPY - x _ _ - l_ Y' - si- - G ARAHTFfS 1CATED� SHALL -- _ - - - e' _ h+D "HEREON IUJIi. - , - ::�,- - - - - _ THE ERSO fOR• � - OML T WHOM T YE -.v_- - - 5'{ _ -Is _ •-:--f"..,--:--.1-%'' - -. _ - - -- - - - _ - - OREPARFD,Art HIS BEHALF TO THE: - - - _ _ - `ANY•iaOYE AL' _ - - ▪- �k _ - �r r_ tiff CO1NP RIVMFtIT A 'ANG -c - �- - v Y'7 r `�l. rt�.P, -r T•y- - � _f. •',"=-:']'-':.:••••,',,-;7,--; __ - _ - _ - __ _ - �:LENDR4G ti$_T . • LISTED•HER80N,=AND=-�'� - - _ _ �; j _ mi 1HE - r- - t' '� �lf ARE Nb 'xI •l l T+a' �M-:.y". M"(�/� � 'JM `�T-+ j�,`�y.,� _�+ 7M -_ _ __ _- _ ..3 '• -'y-1 __ it- - - y 1 „„,_,....,.•„,..‘.,--_,-,,,