HomeMy WebLinkAboutStulsky cr
or cm,
„,° � �a Town Hall, 53095 Main Road
� � P.O. Box 1179
'�® O �s��®��9' Southold, New York 11971
JUDITH T.TERRY - �� TELEPHONE
TOWN CLERK ' ��/ (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. 930-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STULSKY, ANTHONY
Mailing Address 1 760 SEAWOOD DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 760 SEAWOOD DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2765
Tax Map No. section 79.00 block 8 lot 10.000
Cross Street NORTH BAYVIEW ROAD
Date Of Last Pump Out 0/00/80
Issue Date: 11/25/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
- _ , r
OFFICE, OF THE TOWN CLERK , S1F�G-----
Town of Southold C Application No.'
Judith T. Terry, Town Clerk ' r . y
Town Hall, 53095 Main Road '4',.t:' iv.
I Residential
P. 0. Box 1179 F �`L' ` `''
.�� � �� Non-Residential
Southold, New York 11971 ‘4,-, "` •; ���`�-
Telephone Q( /P
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
• SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ,
DATE // - Z�--- CY(
OWNER NAME: �n oh! �/c
1
OWNER MAILING ADDRESS: 1 (00 ,6 ,R
OWNER PROPERTY ADDRESS: _ 5C-E-eln . --
OWNER TELEPHONE NUMBER: 765"---'Q/76C.---
1 f
TAX MAP NO. : Section 19 Block ? Lot /0
CROSS STREET: eN 0 r1'1,, —2,A.y U;e(,) Rd
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 7 New Existing , '
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ? /9(13"G•=-
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.)
•
SimsN^.ture of Applic ,',
RECEIVED BY:
/ (.;(-)4J%------:
own `Clerk's Office
DATE: /( (_,5 1 q`( , ,
} ti
s
I�CiVCIq 'e I�
(
I
___(4) 00 cl