HomeMy WebLinkAboutSledjeski (2) Owl
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tRD 1 :1 Town Hall, 53095 Main Road
�`' P.O. Box 1179
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Southold,., Southold, New York 11971
JUDITH T.TERRY �ILs,." 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. 1306-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SLEDJESKI, THOMAS
Mailing Address 1 BOX 738
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 WELLS ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8619
Tax Map No. section 126.00 block 8 lot 24.000
Cross Street ALBO DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 11/14/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK. c,VFFOkee,
Town of Southold �Q� C'� Application No. �c3Db
Judith T. Terry, Town Clerk O '� `5':.:
Town Hall, 53095 Main Road -s 7 $10.00 - Residential
P. O. Box 1179 cn "0
7 ;
$25.00 - Non-Reside tial
Southold, New York 11971 Os0• .11
Telephone = j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ j Q'./
DATE , 0 tIZ1 '
OWNER NAME:P-11,o(Y L_R_c( moi„' • •
OWNER MAILING ADDRESS: 3g
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OWNER
1q5)---OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: a,J'— wi,
TAX MAP NO. : Section/ al co Block e Lot /
CROSS STREET: !`J Le d 11(.)1
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing x
Residential )( Non-Residential
DATE OF PREVIOUS PUMP-OUT: •
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.)
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Signa re of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE: - Ngo '
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