HomeMy WebLinkAboutMysliborski NINTH T. TERRY ,Town Hall, 53095 Main Road
TOWN CLERK O T P.O_ Box 1179
REGISTRAR OF VITAL STATISTICS �` - Southold, New York 11971
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�� Fax (516) 765-1823
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2034-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MYSLIBORSKI, BRUNO
Mailing Address 1 600 BAY SHORE ROAD -
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 600 BAY SHORE ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1745
Tax Map No. section 53.00 block 4 lot 39.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •CSFa,r�'-
Town of Southold � :z CQ ' Application•
Judith T. Terry, Town Clerk " $10.00 - Residential
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Town Hall, 53095 Main Road " z=, -'�
P. O. Box 1179 En � 1* ,
$25.00 - Non-Residential
Southold, New York 11971 � 0 ��`�
Telephone ; 4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ fO £
DATE ( ` /7r f
OWNER NAME:
OWNER MAILING ADDRESS: . DD itttd frit ../ it j _
OWNER PROPERTY ADDRESS : 66 1 51 11[./ _41_4( ' " j' ► `
OWNER TELEPHONE NUMBER: /-t/(7..- (7
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE• OF- SYSTEM: Septic Tank New Existing
Cesspool /( New Existing
Residential r , 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, approximately, to building and closest road.)
Signature of Applicant �t
RECEIVED BY: - -
Town Clerk's Office
DATE:
Y ,�o r I�