HomeMy WebLinkAboutSidor (2) 40 'jog
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"r 4 Town Hall, 53095 Main Road
4' P.O. Box 1179
�-�_,j/ 1Zsi i Southold, New York 11971
JUDITH T.TERRY '_�� y�r ��l FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 967-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIDOR, EDWARD
Mailing Address 1 RD 1, BOX 166 A
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MARYS ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8810
Tax Map No. section 139.00 block 4 lot 12.001
Cross Street COUNTY ROUTE 48
Date Of Last Pump Out 0/08/83
Issue Date: 12/22/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK SWFOU
Town of Southold *, , w.. ,, C4--- Application No.'7
Judith T. Terry, Town Clerk '• �_ k, y
Town Hall, 53095 Main Road ~ i {` -4 7 Residential
P. O. Box 1179 to 'r ,V:'.2- .--'' ' ; Non-Residential
Southold, New York 11971 O ' F % t'.
4p 0-
Telephone - ---
- -_ 1_ ., e. .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT ,
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or .CESSPOOL ,
Operation Permit No.
Fee $ 4/a 6 - -
DATE icP - /S- -- Fr
OWNER NAME: 40t 4 S//c,e , .
OWNER MAILING ADDRESS: Pi) "/ 1107.1( i6 1
/71/9 /17T'o7ciae/, .B //,952_
r
OWNER PROPERTY ADDRESS: Mg/'5 a
-4111 / c/ ,- /77X.2
OWNER TELEPHONE NUMBER: 1/4c/,6' - X9.8 -- .7d
TAX MAP NO. : Section 13 ? Block V Lot /.=, , /
CROSS STREET: 6,/0 Xt 97
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - v New Existing ,j
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: i3/MY, - C/13
LOCATION MAP: \ Must be attached hereto before permit may be issued.
' \(Locafe building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
, e,eateke_<-4044
Signature of Applicant
RECEIVED BY: ' ,t/V ��'-
own Clerk's Office
DATE:- /'Z(/Z-z1 c-r --' -
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