HomeMy WebLinkAboutSawastynowicz tier ev�*$
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A Town Hall, 53095 Main Road
�. �'� P.O. Box 1179
$ Southold, New York 11971
��' FAX(516)765-1823
JUDITH T.TERRY TELEPHONE(516) .65 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. 1414-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SAWASTYNOWICZ, IRENE
Mailing Address 1 1100 ALVAH'S LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1100 ALVAH'S LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6863
Tax Map No. section 109.00 block 2 lot 18.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/83
Issue Date: 3/14/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE_ OF THE TOWN CLERK if OF
Town of Southold Q L'
C , OG; Application NI c `�-P4
Judith T. Terry, Town Clerk . ,, w :l
Town Hall, 53095 Main Road -x,<s $10.00 - Residential
p. 0. Box 1179 u-3 "r 14;; M' gi
X =1 • v $25.00 - Non-Residential
Southold, New York 11971 4 -&� 3{- -.1` .
Telephone ®j : `�� 0•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
F
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /Or ® 6
DATE er/0s6
. OWNER NAME: 6 i S .. 0 co i
OWNER MAILING ADDRESS:_11 0 0 A ,G,- (.71-f( S 47.3,6r-e,
(' a l v -e_.. / ' i .I. / /9&.s<
OWNER PROPERTY ADDRESS:_15 _ —_ __._---- ` _T
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OWNER TELEPHONE NUMBER: "73 0'--6 er''''‘‘-
a 1
TAX MAP NO. : Section Block Lot
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CROSS STREET: , IE
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
r--
Residential < Non-Residential
DATE OF PREVIOUS PUMP-OUT: / r3
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.)
11
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Signature of Applic. t
RECEIVED BY:
Town Clerk' Office -
DATE:
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