HomeMy WebLinkAboutSarych 4
f ri Town Hall 53095 Main Road
P.O. Box 1179
,44
��N ;!� Southold, New York 11971
JUDITH T.TERRYh����� FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1374-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SARYCH, GENEVIEVE
Mailing Address 1 665 GILLETTE DRIVE
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 665 GILLETTE DRIVE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-2247
Tax Map No. section 38.00 block 4 lot 3.000
Cross Street MANOR ROAD
Date Of Last Pump Out 10/00/78
Issue Date: 1/31/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
, III
OFFI, .E OF THE TOWN CLERK �cvFFON,
Thwn of Southold Q C'� Application No. $)3 �)/
Judas i T. Terry, Town 'Clerk t `xa mak :1•
1
Town Hall, 53095 Main Road _x . $10.00 - Residential )<,_
P. O. Box 1179
�" '� '� $25.00 - Non-Residential
cry ,�3��;: ��
Southold, New York 11971 O - . �c _'•�`
Telephone j `N
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
To:- - -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /Cy ,, (..5-t
DATE
OWNER NAME: I e i ✓ i eve Sa -y C- ti
OWNER MAILING ADDRESS: 46 5 Alf-d - �. e1
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7- .A -)
TAX MAP NO. : Section 3 " — Lot iS
CROSS STREET: w, /eZ )
TYPE OF SYSTEM: Septic Tank New Existing t/
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: (It-) (L/78�
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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