HomeMy WebLinkAboutShaskin A Town Hall, 53095 Main Road
i �® P.O. Box 1179
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_p,1 Southold, New York 11971
JUDITH T.TERRY •.� _.�_�= TELEPHONE
TOWN CLERK (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. 3576-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SHASKIN, BORIS AND OLGA
Mailing Address 1 P. O. BOX 1649
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1105 CAPTAIN KIDD DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4870
Tax Map No. section 106.00 block 5 lot 12.000
Cross Street ZENA ROAD
Issue Date: 1/21/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'OFFICE OF THE TOWN CLERK .c�vFFaft°"--
Town of Southold ; 44% Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road fl $10.00 - Residential
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 O•'�f0:`• . ��
Telephone .�f
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE / JA, Sq
OWNER NAME: 11 O I-1 5 -I- OC-(A-
OWNER
(.- q-OWNER MAILING ADDRESS: ' (� zld`V )i9L1OJ
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OWNER PROPERTY ADDRESS: 410 �J 'C''dp / k / tdd JJ
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OWNER TELEPHONE NUMBER: 5 17` C5-7d
TAX MAP NO. : Section 4,06 Block 5 Lot__
CROSS STREET: e 'OO
TYPE OF SYSTEM: -Septic Tank New Existing
Cesspool L— New Existing
Residential Non-Residential
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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RECEIVED BY: k - -
Town Cler 's ice
DATE: A /7- -/-