HomeMy WebLinkAboutSawicki 4
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��` P.O. Box 1179
r_y�® ��/'I!�. Southold, New York 11971
JUDITH T.TERRY „���r���` FAX(516)765-1823
TOWN CLERK 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. 1491-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SAWICKI, STANLEY
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-8752
Tax Map No. section 125.00 block 3 lot 4.001
Cross Street ALDRICH LANE
Date Of Last Pump Out 0/00/79
Issue Date: 6/26/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•.. •
OFFICE OF THE TOWN CLERK 4 ct\WFo(,r�'=
Town of Southold �o �QG' Application No./V9/
Judith T. Terry, Town Clerk ,A;;:%.'s* ' $10.00 - Residential �J
Town Hall, 53095 Main Road �, ;� «< -
P. O. Box 1179 cns''"�
;� $25.00 - Non-Residential •
Southold, New York 11971 O `® ' I
Telephone 4;5/614—
(516)
(516) 765-1801 '"•
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for ------
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. !'4/'9(
Fee $ •
fU �
DATE 6 a
S�
OWNER NAME: 04, /
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OWNER MAILING ADDRESS: @vim
OWNER-_PROPERTY_AD-DRFSS — — —
OWNER TELEPHONE NUMBER: ( 9,1"-•--(FA---(9—
TAX
J9,1"-- 5---(9—
TAX MAP NO. : Section i Block 3 Lot If° /
CROSS STREET: - '�'�
i�l V6"4-C1
TYPE OF SYSTEM: Septic Tank New Existing J
Cesspool New Existing
Residential V" Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 9 79
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.)
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Sig ature of Applicant
RECEIVED BY: Gni
Town Clerk's ffice .
DATE: -
9
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