HomeMy WebLinkAboutPolesny JUDITH T.TERRY , ® x e4
Town Hall,53095 Main Road
TOWN CLERK ; V ` ;a P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS •�• 1 �/ Fax(516)765-1823
RECORDS MANAGEMENT OFFICER 111� Telephone(516)765-1800
MARRIAGE OFFICER �_� ®���
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3329-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner POLESNY, MILDRED
Mailing Address 1 1300 STROHSON ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1300 STROHSON ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5991
Tax Map No. section 103.00 block 10 lot 27.000
Cross Street BALDWIN ROAD
Issue Date: 5/12/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C.31FpU('.-
'own of Southold 0�0 t4--_, Application No.
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road g ) $10.00 - Residential
p. O. Box 1179 tri ;'
$25.00 - Non-Residential
Southold, New York 11971 :491
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Telephone _ y
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
• for:
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: Lr/ l r �ef,�e�' 4� /-eS h y'
OWNER MAILING ADDRESS: /300 ,,STRi sto).c) tea,
C etch u_ .v ' /C r 3
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 79Y1-3-99/
TAX MAP NO. : Section /6 3 Block /d Lot n2 _7
CROSS STREET: FR-6 Co,c,(1 4/ •
TYPE OF SYSTEM: Septic Tank
New Existing
Cesspool ✓ New Existing
Residential Non-Residential
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.)
Signature of Ap• 'icant
RECEIVED BY:
- Town •Clerk's Office
DATE:
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