HomeMy WebLinkAboutPolecki OFFICE OF THE TOWN CLERK • • 417�
Town of Southold
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Judith T. Terry, Town Clerk S Z 1;-t`
Town Hall, 53095 Main Road = _ `
P. O. Box 1179 C� �;' r ••
Southold, New York 11971 Alp ® N- ••
Telephone _"'�( [ �� •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 272 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Frank and Helen Polecki
OWNER MAILING ADDRESS: Box 147"
Cutchoque, New York 11935
OWNER PROPERTY ADDRESS: Bay Road
Cutchoque, New York
OWNER TELEPHONE NUMBER: 516-734-5951
TAX MAP NO. : Section 116 Block 2 Lot 12
CROSS STREET: Case Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Never pumped in 27 years.
Judith T. Terry
. Southold Town Clerk
DATE: April 13, 1987 -• _
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cvWFO(,r
Town of Southold Application No. 72.,
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Roada _ n .c 1 Residential
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P. O. Box 1179 � ;r K^ ' � Non-Residential
Southold, New York 11971 ®ACZ, °�•
Telephone
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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 $ /b
DATE
OWNER NAME: FA'A-u /<' PO a- /�L
OWNER MAILING ADDRESS: en /"47 ,ev e, ® (re/,
OWNER PROPERTY ADDRESS: 41 /eI -,9 M b Lam
OWNER TELEPHONE NUMBER: --V(v
TAX MAP NO. : Section J I 6 Block oZ Lot /e;2-
CROSS STREET: Cn S LT Rib.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: TZ-?-t its �c -' 7
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.)
Air
`$.nature of Applicant
RECEIVED BY: Ct/11-6( ��,c�
Town jerk's Office
DATE:
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