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HomeMy WebLinkAboutNawrocki L:t { OFFICE OF THE TOWN CLERKc,OF� Town of Southold � -, CD Judith T. Terry, Town Clerk 1 ;# i ; - ; mow, Town Hall, 53095 Main Road ca P. 0. Box 1179 Southold, New York 11971 Q Telephone (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 501 Residential X Fee $ 10.00 Non-Residential Septic Cesspool x NAME OF OWNER: Frank Nawrocki OWNER MAILING ADDRESS:South Harbor Lane Southold, New York 11971 OWNER PROPERTY ADDRESS: South Harbor Lane Southold, New York OWNER TELEPHONE NUMBER: 516-765-3117 TAX MAP NO. : Section 75 - Block 4 Lot 7 CROSS STREET: Main Road (Rt. 25) TYPE OF SYSTEM: Septic Tank New Existing Cesspool X New Existing x Residential X Non-Residential DATE OF PREVIOUS PUMP-OUT: Sept. 1986 i ; !_ .i � '' • . -err ,r Southold Town Clerk DATE: December 1, 1987 (TOWN SEAL) OFFICE OF THE TOWN CLERK cOF()Li' Town of Southold , Application No. Judith T. Terry, Town Clerk ,• , Town Hall, 53095 Main Road .µc : 1 Residential P. O. Box 1179 ` '' : hi ; Non-Residential Southold, New York 11971 Telephone .( • �► (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION - ----for -- - OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. ..A'd/ Fee $ / /6,, be) DATE j`—'2/ /7 7 OWNER NAME: �,�/1 LIJrQC=k/ OWNER MAILING ADDRESS:<,„Yiet /jp, /,g/7, ©""7-4 / /' / 77/ OWNER PROPERTY ADDRESS: Z'ol{JL/J /1/4 e3d )f4-4'� D ra lo/ / ,/1// /17?" OWNER TELEPHONE NUMBER: 5/6— 7� f�3 // 7 TAX MAP NO. : Section Block Lot CROSS STREET: 4" (del— 0151 • TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing 1� Residential j l/— Non-Residential DATE OF PREVIOUS PUMP-OUT: l 7(rC 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.) 4,41,A Signature o Applicant ,RECEIVED BY: •,41 / n CI_rks:Vice DATE: II/J77 mo' 5-6;1-/i0/2440, e— r, rt