HomeMy WebLinkAboutSurozenski K
.,(0 Town Hall, 53095 Main Road
Vmss_,.
O 1 i P.O. Box 1179
?_ ®� � �� i!° Southold, New York 11971
JUDITH T.TERRY %�
-_ ..sir 'ii 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. 1239-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SUROZENSKI, ANTONE
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3889
Tax Map No. section 75.00 block 3 lot 5.000
Cross Street SOUTH HARBOR ROAD
Date Of Last Pump Out 1/00/86
Issue Date: 9/01/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c3�FFOUr•'-
Town of Southold Q C'
_ Q ' Application No. X023/
Judith T. Terry, Town Clerk r rr
.G $10.00 - Residential
Town Hall, 53095 Main Road 8 Og
P. O. Box 1179 ('-3
z $25.00 - Non-Residential
Southold, New York 11971 O �
Telephone . OI , Q. ►��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
SEP Al ig for
1e ® ®�� OPERATION PERMIT
Tom CfiSEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME: 4/7/7-6/7-e. 57/fieeZei)/6:4/ •
OWNER MAILING ADDRESS: iling.//j/ 09-4
Sin 0t- 456 2 ;/Yy 1/971
OWNER PROPERTY ADDRESS: /274-/A/ -BAD
t-M/c
OWNER TELEPHONE NUMBER: 1‘
TAX MAP NO. : Section / 76-- Block Lot 4 73 n'?
CROSS STREET:MAI/V — jl8,-ResT I4/1-eSec 1-1AQi at-Pe
•
TYPE OF SYSTEM: Septic Tank New Existing I-• •
Cesspool lr" New Existing
Residential `� Non-Residential
DATE OF PREVIOUS PUMP-OUT:34ND4ati — 19g6
LOCATION MAP: Must be attached hereto before permit may be issued. _=
-(Locate building and system; 4ve north arrow and feet
?rr rrximately, to building and closest road.)
,/ •
Signature of Ap•Icant
RECEIVED BY: (:) ,
Town Clerk's Office
DATE:
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