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HomeMy WebLinkAboutSawicki (3) • OFFICE OF THE TOWN CLERK FOU( - Town of Southold ��� CcG Judith T. Terry, Town Clerk 1,`` 1t Town Hall, 53095 Main Road Iti � % � '` P. O. Boz 1179 ftp, Southold, New York 11971 ' p Telephone ®1 411 (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 417 - Residential X ' Fee $ 10.00 Non-Residential Septic Cesspool X NAME OF OWNER: John Sawicki / Helen Sawicki OWNER MAILING ADDRESS: P.O. Box 404 Mattituck, New York 11952 OWNER PROPERTY ADDRESS: Bayer Road Mattituck, New York OWNER" TELEPHONE NUMBER: 516-298-8679 TAX MAP NO. : Section 107 Block 9 Lot 23.1 CROSS STREET: Grand Avenue TYPE OF SYSTEM: Septic Tank New Existing Cesspool X New Existing X Residential X Non-Residential DATE OF PREVIOUS PUMP-OUT: Unknown - I ,di+h T Tcrry Southold Town Clerk . • DATE: August 28;, 1987 - (TOWN SEAL)- Of OFFICE OF THE' l`OWN CLERK �FF,O Town of Southold 0��� t CQG Application No /7 Judith T. Terry, Town Clerk , 7 -4 -16 Residential Town Hall, 53095 Main Road P. O. Box 1179 crs 'ft .`' Non-Residential New York 11971 O� .x„ Southold, Telephone (516) 765-1801 TOWN OF SOUTHOLD ' . SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL' Operation Permit No. Fee $ /0;e - DATE c204-14c T ' OWNER NAME C- (.) Sty} WCCK i / 6 SA'wLc 1 OWNER MAILING ADDRESS: ,4 BOX 4'O / ', Y1m/f=TT7-nx , ./(7 11 qcs'9 OWNER PROPERTY ADDRESS: A ER_ Ric). nn OWNER TELEPHONE NUMBER: 5767— ' 1©7_9—Z3, 1 TAX MAP NO. : Section Block Lot CROSS STREET: j A/ Ave TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing ›S 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.) 1,1„/S, Signature of Applicant RECEIVED BY: Town Clerk's Office DATE: d '6