HomeMy WebLinkAboutWaloski ill' �
, ® ads
; Town Hall, 53095 Main Road
P.O. Box 1179
® �'I Southold, New York 11971
JUDITH T.TERRY ' '�' 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. 1497-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X '
Name Of Owner WALOSKI, BLANCHE
Mailing Address 1 P. O. BOX 1147
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 370 MEDAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8764
Tax Map No. section 113.00 block 10 lot 8.001
Cross Street HOWARD AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 7/17/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK CS�FF�(�•�''
Town of Southold �� <_ , C'Q_ '; Application No. 4/9
Judith T. Terry, Town Clerk f,*t!t` s �' $10.00 - Residential V
Town Hall, 53095 Main Road 4.S.0 -
p. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 O � Ng ��`
Telephone j ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit Np.
Fee $ i 0
DATE 7- X3--9
OWNER NAME: �j1-.}P03C� , \ivainsK.1
OWNER MAILING ADDRESS: n ' 5 \ L/14i
mrl c.9V 1, 1-9
OWNER PROPERTY ADDRESS : 3 `1 ® Iw 2 A1/
11-1,1 'T`T- 1�'�1� ,�•
OWNER TELEPHONE NUMBER: O' ] S L94
// 3 - /6 - f, /
TAX MAP NO. : Section Block Lot 1'6 �' 1
CROSS STREET: hY'A' , --
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool NIN, New Existing
Residential 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.)
./&/7,4 ' GIl
Signature of Applicant
RECEIVED BY: /1-71 ��
Town Clerk's`Office
•
DATE: `/ 'V9d
• !_ala' a "i644 ? g 044 7g ,
3 � yit.,e4cy “, /t ,r24-t-e-x-e,
_ Q
- _ _ II(ate'Ziel "V
c aS'S Nob. ,,,rqSca,
1
591 .
...1
f ,
r
6UT14 '
1. 0Z-tirT Q6
l'.- '
,r
o
4 ,s
tcs..-,; ,, ( 6
- vt: ,,-,,- * Hot i 5ff . , .• ' , 1_,,:.-- '
kui ,
a 4 ' 1 , 910 :. j -
ort / q
JLCOT .7g
. y
II ' ,
l ! j '
/0(0, g ao t V 0 .
' ti 0 kb .ft'1.E9 % Avg:
_