HomeMy WebLinkAboutSobotka , 1111
Town Hall, 53095 Main Road
,7" _ moi`' P.O. Box 1179
• 0 Southold, New York 11971
JUDITH T.TERRY „ of 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. 985-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SOBOTKA, ROSE
Mailing Address 1 43750 MAIN ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 43750 MAIN ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-3186
Tax Map No. section 75.00 block 6 lot 12.000
Cross Street WELLS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/10/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
se
OFFICV\OF THE TOWN CLERK cOFai'
Town of Southold ? C
Q ' Application No.
Judith T. Terry, Town Clerk • �� pVt
a �►
Town Hall, 53095 Main Road 8 IV :'� 1 Residential
P. O. Box 1179 cr3
'�tik;• � • Non-Residential
Southold, New York 11971 O0 �0� �•••
Telephone /( `1 '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit / J \
Fee $ •
DATE
OWNER NAME: <�n13 T/(L( /PoS �
OWNER MAILING ADDRESS: 1/ 3 7S U /vi , /./j R 410
OWNER PROPERTY ADDRESS: A Ail
OWNER TELEPHONE NUMBER: (p S^- 3 1 P 6
TAX MAP NO. : Section Block Lot )
CROSS STREET: vu
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 'e, New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: L:' - /( ,- (Ff
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 Applicant
RECEIVED �t�K-c�u •
4%-44V�Town 'lerk's ffice
DATE:
Town Clerk Southold
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