HomeMy WebLinkAboutNowachek OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179 Ln
Southold, New York 11971 O
Telephone.( y►���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 21 Residential X
Fee $ 10 . 00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Anthony G. and Helen M. Nowachek
OWNER MAILING ADDRESS: P. O. Box 355'
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: 4905 Pequash Avenue
Cutchogue , NY 11935
OWNER TELEPHONE NUMBER: 298-5511 (Office)
TAX MAP NO. : Section 110- Block 4 Lot 1
CROSS STREET: S/E corner of intersection with Fleetwood Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing Two
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT:
Judith T. Te
Southold Town Clerk
DATE: August 20, 1986
(TOWN SEAL) " .
OFFICE OF THE TOWN CLERK �AffQ(�.
Town of Southold 0�� CQG Application No.�
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road - Residential I/
P. 0. Box 1179 Non-Residential
Southold, New York 11971 `
Telephone0.(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. oZ/
Fee $
DATE August 14, 1986
OWNER NAME: ANTHONY G. & HELEN M. NOWACHEK
OWNER MAILING ADDRESS: P.O. Box 355
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: 4905 Pequash Avenue, -
Cutchogue, New York 11935
OWNER TELEPHONE NUMBER: (516) 298-5511 (office)
TAX MAP NO. : Section 110 Block 4 Lot 1
CROSS STREET: S/E corner of intersection with Fleetwood Road
TYPE OF SYSTEM: Septic Tank New 'Existing
Cesspool x New Existing two (2)
Residential x 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.)
Copy of survey with designation annexed hereto of
location of pools
ANTHqNY G. & ELEN M. NOWACHEK
By ut�-
Si n ure of Applicant
Anthony G. Nowachek
RECEIVED BY: p ��
'Town CI rk's Office
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