HomeMy WebLinkAboutMysliborski OFFICE OF THE TOWNCLERK • •cOFO[KeO -
Town of Southold ��
Judith T. Terry, Town Clerk ;4 x `
Town Hall, 53095 Main Road 1 " •
P. O. Box 1179 t1 n13.ezA 0. 'g
Southold, New York 11971 ' `'O ® "'" �` �- •�
Telephone %.10/ $� •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT -
SEPTIC TANK or CESSPOOL
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Operation Permit No. 428 Residential x
- Non-Residential
- Fee $ 10.00
Septic Cesspool X
- NAME OF OWNER: Henry H. and Carole J. Myslborski
OWNER MAILING ADDRESS: 626 Bayshore Road
Greenport, New YOrk 11944
OWNER PROPERTY ADDRESS: 626 Bayshore Road
Greenport, New York 11944
OWNER TELEPHONE NUMBER: 516-477-1308
TAX MAP NO. : Section 53 Block 4 Lot 37
CROSS STREET: Kerwin Blvd. ;
TYPE OF SYSTEM: Septic Tank New- ' Existing
Cesspool X New Existing X •
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 23, 1987
Judith T. Terry
Southold Town Clerk
DATE: September 18, 1987 -
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(TOWN \SEAL)
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OFFICE OF THE TOWN CLERK '��FFOU
Town of Southold . - .CQ": Application No. y�"
Judith T. Terry, Town Clerk �% �►
Town Hall, 53095 Main Road a _n : :G Residential
P. O. Box 1179 u' .: " _ ' �, Non-Residential
Southold, New York 11971 O 'CII, `� '' .$Telephone _ ( � '
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
-for
eve
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /7b.
• DATE q-15 -g7
OWNER NAME: f- eAJJ j )i d (_ C'�.,-b I e r. /1'1 i S f bor S /C i
OWNER MAILING ADDRESS: rqo? 6 P)Arsho re ifoad
(•i-I-e e nf o 1,---r L..,r.. 119V1/
OWNER PROPERTY ADDRESS: SR 1\A ,p __
OWNER TELEPHONE NUMBER: k-r77 /,;J g
y TAX MAP NO. : Section 5'3 Block 7 Lot 3 7
CROSS STREET: Kerb., i to (el Vc •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ✓ Non-Residential
- DATE OF PREVIOUS PUMP-OUT: Nat. 4 3 . 19' ' 7
LOCATION MAP: Must be attached heret� be ore permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
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CN\ iA i:k.
gnatuof Applicant
RECEIVED BY: de,,„ .
Town ferk's ffice
DATE:
SEP 171
Town Clark Southold
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