HomeMy WebLinkAboutPekunka JUDITH T. TERRY .1
� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER ! Fax (516) 765-1823
604„ �r®��!, 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. 1866-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PEKUNKA, MITCHELL
Mailing Address 1 475 PIPES NECK ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 475 PIPES NECK ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1153
Tax Map No. section 53.00 block 1 lot 6.000
Cross Street KERWIN BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 4/06/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ic,VFFfl(,��'=
Town of Southold �� } • - CQ�= Application No. /e
Judith T. Terry, Town Clerk �► .
$10.00 - Residential
Town Hall, 53095 Main Road s
P. O. Box 1179 Lc") 1- 4'' ` $25.00 - Non-Residential
Southold, New York 11971 Oo`= �0�•�
Telephone _ .( '•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 17/4/f, "
OWNER NAME: iiitaall
OWNER MAILING ADDRESS: e/752f 6�-�`�
W � y,
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 5/,6 Li/ - / /3-3
TAX MAP NO. : Section 5 3 Block / Lot
• CROSS STREET:
/34144'.
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.)
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Signature of Applicant
RECEIVED BY:
own VE�•Clerk's Office
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DATE:
APR G 199)
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1\4/7 -/06
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