HomeMy WebLinkAboutUrbanski 41. tfaire--
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JUDITH T.TERRY '-1*- x,,,00° 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. 1438-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner URBANSKI III, JOSEPH P.
Mailing Address 1 URBANSKI, ELLEN. M.
Mailing Address 2 P. O. BOX 792
City St Zip MATTITUCK NY 11952-0000 .•
Property Address 1 445 OAK STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8023
Tax Map No. section 141 .00 block 1 lot 20.000
Cross Street YOUNGS AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/16/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cl\FFOUr
Town of Southold •
�. H QG Application No. g
ttr
Judith T. Terry, Town Clerk 4f �'
Town Hall, 53095 Main Road w $10.00 - Residential
P. O. Box 1179 u-3 ' ' WISfat
i $25.00 - Non-Residential
Southold, New York 11971 _ O%® f`
Telephone •
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD 'WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10.00
DATE McicCh L.3 tq o
OWNER NAME: 3C_LETr 1 U he nck \\€ 1.:(r li 661
OWNER MAILING ADDRESS: dI PC)• Eok 1 -_
Mc - dc_ 1J� 1Gs�—
OWNER PROPERTY ADDRESS: L Oct S\-_
OWNER TELEPHONE NUMBER: 2°‘, - (n.j
TAX MAP NO. : Section \`l ht 00 Block O),OO Lot 0a0,,_ C O
CROSS STREET: "�-t (6NW(I k)t e. AN (`141A- -fiDnA I( se $o (
js
TYPE OF SYSTEM: Septic Tank lr New Existing
Cesspool New Existing V
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: tic'.l. " 1116-ty r
LOCATION MAP: Must be attached heWo forelpe fFm oy be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
ay.
Signature of App icant
RECEIVED BY: 4, /„.„
T.wn C erk's Office
DATE: f 90
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