HomeMy WebLinkAboutSledzieski s''t®gv __.
Town Hall, 53095 Main Road
®��® r 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. 1300-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SLEDZIESKI, MARTHA
Mailing Address 1 ROUTE 48, RFD BOX 354
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 ROUTE 48
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1323
Tax Map No. section 44.00 block 4 lot 4.000
Cross Street CHAPEL LANE
Date Of Last Pump Out 0/00/88
Issue Date: 11/13/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
dr' • 00.
OFFICE OF THE TOWN CLERKcuFFV(,(
Town of Southold � ..- C�G� Application No. ? 5dd
Judith T. Terry, Town Clerk � ' ' 79 /
Town Hall, 53095 Main Road * raj } $10.00 - Residential �/
P. 0. Box 1179 '` l'4 ` � hi
:;: $25.00 - Non-Residential
Southold, New York 11971 O �_ 0".°
Telephone 01
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- - _ - - for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE O c,..)it , 3
OWNER NAME: Pq ii1r11/1, d4 S S 4K. t •
OWNER MAILING ADDRESS: .- /V-,, L 0 /'F,7 - k 351/
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L / 1
-- - - OWNER PROPERTY ADDRESS:
- _ /
OWNER TELEPHONE NUMBER: 9 7 7 - / 3 3
TAX MAP NO. : Section /1-/-4( Block el Lot
CROSS STREET: a t
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / cL
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.)
Signature of A y: icant
RECEIVED BY: A/,
Town Clerk's 0 fice
DATE: ///7 / — 2
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