HomeMy WebLinkAboutSzymczak OFFICE OF THE TOWN- CLERKFo
Town of Southold c.0C��
Judith T. Terry, Town ClerkPo4. �
Town Hall, 53095 Main Road • �: —
a
P. 0. Box 1179 cn
Southold, New York 11971 _p ® �O�
Telephone -2".70,/ s
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
•
SEPTIC TANK or CESSPOOL
Operation Permit No. 461 Residential X
Fee $ 10.00
Non-Residential
Septic Cesspool x
NAME OF OWNER: Tilli Szymczak
OWNER MAILING ADDRESS: 1200 Skunk Lane
Cutchoque, New York 11935
OWNER PROPERTY ADDRESS: 1200 Skunk Lane
Cutchoque, New York
OWNER TELEPHONE NUMBER: 516-734-5294
TAX MAP NO. : Section' 97 Block 3 Lot 13.1
CROSS STREET: Route 25
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1983
Judith T. Terry
Southold Town Clerk
•
DATE: October 14, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK S�FFOUr
Town of Southold �� ,k CQG= . Application No.
Judith T. Terry, Town Clerk �� y :\
Town Hall, 53095 Main Road ~ _ � :'� I Residential
P. O. Box 1179 W.* Non-Residential
Southold, New York 11971
Telephone
(516). 765-1801 _ 1
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
_ - - for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ • - -
DATE /6//0-7
OWNER NAME: 77/ J t5.2Y/11cZAj K
OWNER MAILING ADDRESS: 77ZZ/ 5ZX%'%CZA/t"
,'Jeki ,Lf IV (l/re/70 1)=04/ //,r/j
OWNER PROPERTY ADDRESS: ,574 /f5 46707,,E
OWNER TELEPHONE NUMBER: '7,7X- (5,,,5>1L
TAX MAP NO. : Section 47 7 Block .3 Lot /3 /
CROSS STREET: Po tP c„--L5
TYPE _OF SYSTEM: Septic Tank New Existing
Cesspool Ipdelfr`J New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximtely, to building and closest road.)
ignature o Applicant
RECEIVED BY:
RECEIVE® Town Clerk's Office
DATE: atTid. 1 7
Town Clark Southold
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