HomeMy WebLinkAboutSlaga Town Hall, 53095 Main Road
�� P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY 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. 1481-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SLAGA, JUSTYNA
Mailing Address 1 GRIFFIN, MARTIN
Mailing Address 2 P. O. BOX 445
City St Zip MATTITUCK NY 11952-0000
Property Address 1 PACIFIC STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5175
Tax Map No. section 141 .00 block 4 lot 12.000
Cross Street SOUND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/12/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK
Town of Southold ; Application No. /4176
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a �.,i- „ $10.00 - Residential
P. 0. Box 1179 cry `` ;
• -- tr.,,; �. $25.00 - Non-Residential
Southold, New York 11971
Telephone '40 itgt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD 'WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /`L'L v-v
DATE C; ,1.4. ,, (9)
OWNER NAME: S dr /Vl V;
OWNER MAILING ADDRESS: / c a, 80 )1 y y,
OWNER PROPERTY ADDRESS: t fiL
M -T k 1')„f /) ?
OWNER TELEPHONE NUMBER: 6-7 7
TAX MAP NO. : Section / / Block L/ Lot /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool Y New Existing
Residential (7- Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,717 „2e( Fe
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.)
4111 OP •
Sign; ure of Applicant 1-
RECEIVED BY: _
ale*erk's Office
DATE: JURE 12 1490
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