HomeMy WebLinkAboutPolatnick ,
JUDITH T. TERRY � Town Hall, 53095 Main Road
TOWN CLERK N P.O. Box 1179
REGISTRAR OF VITAL STATISTICS l� Southold, New York 11971
MARRIAGE OFFICER
> e Fax (516) 765-1823
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�4® OY®.�!` 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. 1873-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner POLATNICK, JEROME
Mailing Address 1 1230 CRITTENS LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1230 CRITTENS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3703
Tax Map No. section 70.00 block 12 lot 7.000
Cross Street PARKWAY
Date Of Last Pump Out 0/00/00
Issue Date: 4/09/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK FO -
Town of Southold , _� Cy: Application No./ (73
Judith T. Terry, Town Clerk . _ A
Town Hall, 53095 Main Road ' $10.00 - Residential
P. O. Box 1179 ^`` f=n- $25.00 - Non-Residential
Southold, New York 11971 O7.® ,; ..< �•`
Telephone : ,{ 411
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $10o
DATE *I,
AO
OWNER NAME: PO4,4-rNiCe
OWNER MAILING ADDRESS: I 40.444_
'4` / , 'Y 1197/
OWNER PROPERTY ADDRESS: •u2._
OWNER TELEPHONE NUMBER: 16S-- X703
TAX MAP NO. : Section 1Q, 0c®7Block Lot
CROSS STREET: gaAkt.Als
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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#01tc,.te
Signature Applicant
RECEIVED BY: '5°1
Town Clerk's Office
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DATE: LAPLI- ,(- 1I