HomeMy WebLinkAboutWaloski (2) oil COF W.
JUDITH T. TERRY ; V Town Hall, 53095 Main Road
TOWN CLERK Q
Fri
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER yQ Fax (516) 765 1823
',y®1 aid �1D 01� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2030-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WALOSKI, DAN
Mailing Address 1 P. O. BOX 195
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 280 YOUNGS AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4835
Tax Map No. section 141 .00 block 1 lot 31 .000
Cross Street PINE STREET
Date Of Last Pump Out 0/00/00
Issue Date: 12/29/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c��FFO(,r '- 77
Town of Southold G� e, Application No. oo�'C.)
Judith T. Terry, Town Clerk $10.00 - Residential
Town Hall, 53095 Main Road t
p. O. Box 1179 �' i $25.00 - Non-Residential
Southold, New York 11971 ���`�
Telephone
01• �s •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION-
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10 ,0d
DATE - - 2
OWNER NAME: D s
OWNER MAILING ADDRESS: . C ‘.160 A' CAP'S •
�eC) SOK t�
OWNER PROPERTY ADDRESS: 'f(�,� AjOS /4Jaf
,4 K X 14. 5
OWNER TELEPHONE NUMBER: 6-1 6
TAXI MAP NO. : Section Block Lot
CROSS STREET: '/O0 JV, '
TYPE OF, SYSTEM: Septic_Tank - : New Existing
Cesspool ye/ Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: C C__ ` O41 / dR- $
-5z, 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.)
Signature of Applicant
RECEIVED BY: OCA -
Town Clerk's Office
RECEIVE®
DATE:" -
DEC 14'0
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