HomeMy WebLinkAboutPoliwoda DLer
N
to
. Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ® `� si°�� FAX(516)765-1823
%�%�����` TELEPHONE(516)765-1801
TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1277-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner POLIWODA, JOSEPH W.
Mailing Address 1 520 LAUREL AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 520 LAUREL AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3392
Tax Map No. section 56.00 block 3 lot 1 .002
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/89
Issue Date: 10/19/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
QFFIrCE OF THE TOWN CLERK cvVFUL4-
Town of Southold C'��' Application No./(3
Judith T. Terry, Town Clerk 4 ?.V �'i $10.00 - Residential
Town Hall, 53095 Main Road 8 � y�
P. O. Box 1179 cry -; s^�r � $25.00 - Non-Residential
Southold, New York 11971 O V` :".1'
Telephone #6.4e
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ G0 (5
DATE !v ) )g-ct
'OWNER NAME: ) (5 sg-r Jl YV , �O , i' ►n/4 f(
OWNER MAILING ADDRESS: L6'*Q C t/,' L R Vim,
Jovj- oLd
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7'4
TAX MAP NO. : Section 5 p Block Lot
CROSS STREET: ,�
�Ot Fcy
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ' iz ,�, 14) ( � 9.
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.)
Sig ature of Applicant
RECEIVED BY: la/, «, !: ii J I
own Clerk's 0 fice
DATE: 8
•
C-25s Q6
Cay Pt bsv- f�5'
Cr
w +(ov
I � s