HomeMy WebLinkAboutWenczel I�,///
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T. TERRY #1 ���/I TELEPHONE
TOWN CLERK (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. 1102-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WENCZEL, PETER
Mailing Address 1 WEST SHORE DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 WEST SHORE DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5699
Tax Map No. section 80.00 block 1 lot 115.000
Cross Street OAK DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 5/10/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK Ic.0FUV( -
Town of Southold -% CQ�- Application No. // 09-
Judith T. Terry, Town Clerk . 1,,!4:„ �4
Town Hall, 53095 Main Road .�.' ..-';')I.,,-1,„gI Residential
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P. O. Box 1179 ._ rY� �;. � � Non-Residential
Southold, New York 11971 u.O ® 0���`
Telephone *Q( • ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE SI G/s-
• OWNER NAME: ? -1-4- 0 E e`9e_ 2,•g I
OWNER MAILING ADDRESS: 0. S),, ,e_,E..... b�
sOcYTIOlco iI. ' t174
OWNER PROPERTY ADDRESS: 1.)3, Sh,b21, I)�__ _
.Cel LJ-rw--P0 /C9 ; Y. 11 7 '7 o
OWNER TELEPHONE NUMBER: —26 ® 9 9 ,
TAX MAP NO. : Section ORO, 00 Block 0 / 00 Lot O )-S , ®® 0
CROSS STREET: ®ft ` 1J G2, g U
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool i New Existing
Residential Non-Residential
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DATE OF PREVIOUS PUMP-OUT: 2 / 2 1-1 7 ,,,......,,x--....9,..
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.,)
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,3,1Zj.. ..-14:?
- Signature of Applicant
RECEIVED BY: ,((J.A--Q*---,_
own Clerk's Office
DATE: //b 7
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