HomeMy WebLinkAboutSmulcheski OFFICE OF THE TOWN CLERK ' •c�V�FO(K
Town of Southold 6 &;') , y*.0
Judith T. Terry, Town Clerk `
Town Hall, 53095 Main Road c p f
P. O. Box 1179 cry
At-44 M
Southold, New York 11971 ,I\
Telephone 711 �t��;�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 46 Residential xx
Non-Residential
Fee $ 10.00
Septic Cesspool xx
NAME OF OWNER: Joseph and Amelia Smulcheski
OWNER MAILING ADDRESS: 140 Carole Road, Rt. 2
Southold, New York 11971
OWNER PROPERTY ADDRESS: 140 Carole Road
Southold. New York
OWNER TELEPHONE NUMBER: 516-765-1502
TAX MAP NO. : Section 52 Block 2 Lot 5
CROSS STREET: North Road ( Route 48)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool xx New Existing xx
Residential XX Non-Residential
DATE OF PREVIOUS PUMP-OUT: Jute 16, 1986
Judir f. -Te ry
Southold Town Cle
DATE: September 17, 1986
(TOWN SEAL)
-
OFFICE OF THE TOWN CLERK 1F�
Town of Southold - I (V % Application No.
Judith'T. Terry, Town Clerk y
Town Hall, 53095 Main Road " Residential
P. O. Box 1179 to Non-Residential
Southold, New York 11971 OO �O�•�`
Telephone : .�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /711 9P,C
OWNER NAME: \jasC?1t 1 A S) ut,,,cl41rSl<
OWNER MAILING ADDRESS: /02 C-4 ei9z- ril
So v KoL,b )197/
OWNER PROPERTY ADDRESS: .54-.v.. AS A- 3
OWNER TELEPHONE NUMBER: 7�f /�✓a `'—
TAX MAP NO. : Section / 5 Block c.c. / Lot 2 —
CROSS STREET: -7,211/99,a--4 (Pze- `7Lj )
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool ✓ New Existing l/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ' - /‘-- g6.
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.)
er-
/ Signature of Applicant
RECEIVED BY: ,(: e
Town Clerk's Office
DATE:
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