HomeMy WebLinkAboutNierodzik OFFICE OF THE TOWN CLERK ' •c VFO(�
Town of Southold CD
Judith T. Terry, Town Clerk �'��: s,'_�. i3 ►
Town Hall, 53095 Main Road a 3=
P. O. Box 1179
Southold, New York 11971
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Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2 Residential XXX
Fee $ 10 . 00 Non-Residential
Septic Cesspool XXX
NAME OF OWNER: John Nierodzik
OWNER MAILING ADDRESS: Main Road
Southold , New York 11971
OWNER PROPERTY ADDRESS: same
•
OWNER TELEPHONE NUMBER: 765-1250
TA .. MAP NO. : Section 75 Block 2 Lot 15 . 1
CROSS STREET: South Harbor Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XXX New Existing XXX
Residential XXX Non-Residential
- DATE OF-PREVIOUS PUMP-OUT: unkrLown
Judith-`I",Terry
1117"
Southold Town Cler
DATE: August 15 . 1986
(TOWN SEAL)
i ��� _
OFFICE OF THE TOWN CLERK �c0F0tA-
Town of Southold ' CSG Application No.
Judith T. Terry, Town Clerks. ..c
Town Hall, 53095 Main Road 4... -L.,. �4 Residential
P. O. Box 1179 v' ••. :' Non-Residential
Southold, New York 11971 O ® .,` O�''
Telephone : .� 4 •�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL -
Application No . ,
Operation Permit No.
Fee $ 1 /2D0
DATE ifC . /2g
OWNER NAME: ,,7oh LI/E z//'
OWNER MAILING ADDRESS: N ,i
g®G:✓aV
OWNER PROPERTY ADDRESS: Got- /�
OWNER TELEPHONE NUMBER: 76 '(2- v
TAX MAP NO. : Section 75"
Block Z_ Lot (5—, I
CROSS STREET: 4, i#) gen)
TYPE OF SYSTEM: Septic Tank New Existing i
Cesspool ../ New Existing
Residential •� Non-Residential
DATE OF PREVIOUS PUMP-OUT: �� 71 aGa 'r
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.)
)41-------- al / /f i ,, ,,,
Signature of Applrant
RECEIVED BY: •:C % ; 4411L„a
To, n SI-rk's Office
DATE: ( /i -/ '
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