HomeMy WebLinkAboutSawicki (4) OFFICE OF THE TOWN CLERK s ' FU
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Town of Southold , �
Judith T. Terry, Town Clerk 4
Town Hall, 53095 Main Road =
P. O. Box 1179 cn _
Southold, New York 11971 ' `�'�Yj��/® "" •
Telephone _ ®1 trat
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 330 - Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool x
NAME-OF OWNER: Dr. John V. Sawicki Jr.
OWNER MAILING ADDRESS: Box 34
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: 1790 Deep Hole Drive
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-4446
TAX MAP NO. : Section 123 Block 4 Lot 1
CROSS STREET: Theresa Drive
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Terry
Southold Town Clerk •
DATE: , July 15, 1987 - -
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FOCA- '
Town of Southold , �� . CQG Application No..3
76
Judith T. Terry, Town Clerk Z A
Town Hall, 53095 Main Road =` ' } Residential
p. O. Box 1179 ' : Non-Residential
Southold, New York 11971 Olae. ^V_ $Telephone - lz
765-1801 ®
(516)
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $
DATE -7'
OWNER NAME:.h!' ,®t-ER/ V • Sgwtht "j
OWNER, MAILING ADDRESS: 8.V 34'
m417 rwt/e
OWNER PROPERTY ADDRESS: t777 /eej0 Com.
07 rk N.ic A y /M577,
OWNER TELEPHONE NUMBER: 2-/E-Wille
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% DLL*/115-97 ,fit( ,eg
TAX MAP NO.`: Section 13-rock / Lot /
CROSS STREET:
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.)
• 1 (66
ignature of /Applicant
RECEIVED BY:
Town Clerk's Office
DATE: