HomeMy WebLinkAboutRutkowski (2) Cr
Town Hall, 53095 Main Road
ott P.O. Box 1179
1 T
Vis 'PolsSouthold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERIC TELEPHONE(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. 1141-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RUTKOWSKI, VICTOR AND BARBARA
Mailing Address 1 600 YOUNGS AVENUE, BOX 174 1/2
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 600 YOUNGS AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8025
Tax Map No. section 141 .00 block 1 lot 30.000
Cross Street PINE STREET
Date Of Last Pump Out 0/00/00
Issue Date: 6/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK o�� ////
Town of Southold �� G� , Application Not/7`/
Judith T. Terry, Town Clerk ,M $10. Residential
00 -
Town Hall, 53095 Main Road r Y; <- c�
P. 0. Box 1179 cry i ; $25.00 - Non-Residential
Southold, New York 11971 ` ��`�
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Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /dr66
DATE V/0/ff
'OWNER NAME: dircTtare_ n2tg- (R(5-11-4. t`",
OWNER MAILING ADDRESS: , OC) 7L l y
47M7 ', ) AA y, /( 9 22,
OWNER PROPERTY ADDRESS: 144r /4-y /41-730
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OWNER TELEPHONE-NUMBER: �--�
TAX MAP NO. : Section /9/ Block / Lot 3 0
CROSS STREET: /O0 &/6.' I4 J, •
TYPE OF SYSTEM: Septic Tank New - - Existing
Cesspool New Existing •
Residential Non-Residential
,r
DATE OF PREVIOUS PUMP-OUT: -- - ;� 6/__9)
LOCATION MAP: Must be attached hereto before ermit may be issued. -
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
.rte* t moi.!
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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