HomeMy WebLinkAboutPawluczyk t, `" �� Town Hall, 53095 Main Road
JUDITH T. TERRY .�,� � �'•" ; ; ��_.
} r u- P.O. Box 1179
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TOWN CLERK ® - v t+ Southold, New York 11971
REGISTRAR OF VITAL STATISTICS p`gr5 " ; �_�•.'
Fax (516) 765-1823
MARRIAGE OFFICER ``�® �1
�® �. Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1829-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PAWLUCZYK, BERTHA
Mailing Address 1 BOX 142 RFD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 26170 COUNTY ROAD 48
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6616
Tax Map No. section 84.00 block 5 lot 4.000
Cross Street BRIDGE LANE
Date Of Last Pump Out 0/00/82
Issue Date: 1/09/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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C IIS
OFFICE OF THE TOWN CLERK �SWFOUre,•
Town of SoutholdC Application No. cal
. .>1.,=.-v.---- Olj PP l
Judith T. Terry, Town Clerk . ) ' .. `1 $10.00 - Residential
Town Hall, 53095 Main Road °
P. O. Box 1179 :. :' $25.00 - Non-Residential
Southold, New York 11971 Oaf r `�
Telephone _0.( NO,
(516) 765-1801 ,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT ,
SEPTIC TANK or CESSPOOL
Operation Permit No. laP...
Fee $ 0 , 0 0 '
DATE , 31 )?
OWNER NAME: g.,,v'I-La, Pa.,i,t)LL.L.C."LI IC__
OWNER MAILING ADDRESS: ber?c, I kr
C.c-t ,D,d 3 u e iv Li
_ _ _ --OWNER PROPERTY ADDRESS f 70 C R
OWNER TELEPHONE NUMBER: 7 ( R
TAX MAP NO. : Section F/1" Block 7 Lot 4
CROSS STREET: '8 `\dsc �- . ' -
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool u' New Existing i.-----
Residential
/Residential Non-Residential •
DATE OF PREVIOUS PUMP-OUT: R.-DA I A
LOCATION MAP: Must be attached hereto before permit maybe issued. . .
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
6/170-/-41.- 69.e. / 4 .
Signature of App• .nt
RECEIVED BY: ''''''7.6.4&%/4/
/ , , 4.1
To, n • e/ 's office
RECEIVED
DATE:
JAN 0 3 1992
Southold Town Clerk •
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