HomeMy WebLinkAboutSimchick ,04FOLA(`o(iy`
JUDITH T. TERRY � O Town Hall, 53095 Main Road
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TOWN CLERK p rP.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971 •
MARRIAGE OFFICER Fax (516) 765-1823
%to"®r�,rTelephone (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. 2072-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIMCHICK, WESLEY
Mailing Address 1 5700 ALVAHS LANE -
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 5700 ALVAHS LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6549
Tax Map No. section 101 .00 block 2 lot 18.004
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 3/09/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c0FOU..'�
Town of Southold �® CQG Application No. -22—
Judith T. Terry, Town Clerk s
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 ' 1l' �z $25.00 - Non-Residential
Southold, New York 11971 O ®= ^ ' ���`
Telephone .4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
-for = -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 7 i// tw
y
OWNER NAME:
OWNER MAILING ADDRE'S= : ,;I
1
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7J .5 /4/r
TAX MAP NO. : Section Q / Block Lot /
0
CROSS -STREET: -- - -= --
TYPE OF SYSTEM: _Septic ,Tank _ New Existing
. - Cesspool ---- New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: i Pp'
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.)
(///1/i /
ig °re o Applicagti
.2,14
RECEIVED BY:
Town Clerk's Office
DATE:
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