HomeMy WebLinkAboutOrlowski (2) ( 'illi ��f afr
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rT' Town Hall, 53095 Main Road
V'®� � • P.O. Box 1179
®1 `��,, 'o Southold, New York 11971
JUDITH T.TERRY 41
---.. ,,,01- FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1543-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ORLOWSKI, CHESTER
Mailing Address 1 235 PEQUASH AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 235 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6782
Tax Map No. section 103.00 block 7 lot 31 .000
Cross Street FI RST STREET
Date Of Last Pump Out 0/00/80
Issue Date: 10/03/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFkCE OF THE TOWN CLERK c�vFFOur -
Town of Southold � CQG' Application No. /S-(13
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road 3 r - :'� $10.00 - Residential
P. O. Box 1179 u' �="?rte:` ' ; $25.00 - Non-Residential
Southold, New York 11971 O'M®a ;> $
Telephone •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /is
Fee $ 7 -dW
DATE sid
OWNER NAME: efi —
OWNER MAILING ADDRESS: 3 S p_i_
OWNER PROPERTY ADDRESS:
•
OWNER TELEPHONE NUMBER:. '7 3 CJ 1 7 - z -
TAX MAP NO. : Section / ' Bloc — I Lot '
CROSS STREET: 12i.)./t.,
TYPE OF SYSTEM: = Septic-Tank ' New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS-PUMP-OUT: ri,./113-4-ay /6 - -
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.)
Signa
tire of Applicant
RECEIVED BY: ICJ
Town
Clerk's Office
DATE: . /a/3 7FO -
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