HomeMy WebLinkAboutSepenoski (2) C
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Town Hall, 53095 Main Road
�® O r t P.O. Box.1179
�`-Y_�®� v2„il Southold, New York 11971
JUDITH T.TERRY "_�� 0j 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. 1137-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SEPENOSKI, ANTONE P., JR.
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip ORIENT NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11952-0000
Owner Telephone No. 516-323-3612
Tax Map No. section 18.00 block 4 lot 5.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/09/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cOFQU'
Town of Southold Application No. N37
Judith T. Terry, Town Clerk .14'7
Town Hall, 53095 Main Road ``' `
.0 ) Residential
P. O. Box 1179 tt rn , Non-Residential
Southold, New York 11971
Telephone *el
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O.
_ _
•
DATE
OWNER NAME: ) n 6-?i e-hvs • •
OWNER MAILING ADDRESS: in i' 7610/
Crier/Pi, //957
OWNER PROPERTY ADDRESS: ^14 4d"
Y/e-4'/- /61,;( /( L 7
OWNER TELEPHONE NUMBER: S-76 -
TAX MAP NO. : Section Block Lot
CROSS STREET: , 7v
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.)
#0/
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Signature of ^Tpicant
RECEIVED BY:
Town Clerk's Office
,C17
DATE: t=' TWO
JUN 0 91989 j