HomeMy WebLinkAboutWernikowski fcn ` M�, Town Hall, 53095 Main Road
: . ®� P.O. Box 1179
'-�( '`P� ►' Southold, New York 11971
JUDITH T. TERRY -<,A.,' ./`,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. 1088-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WERNIKOWSKI, FRANK
Mailing Address 1 MAIN ROAD, BOX 13
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2401
Tax Map No. section 18.00 block 5 lot 16.001
Cross Street TABOR ROAD
Date Of Last Pump Out 0100/77
Issue Date: 4/19/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
/ ''
OFFICE OF THE TOWN CLERK Wtl G�
Town of Southold �Q ,_. COG- Application No.
Judith T. Terry, Town Clerk .` fr 'Yx' �z y
,,•.l� `) Residential �
Town Half 53095 Main Road
P. O. Box 1179 cn y-� i �` Non-Residential
Southold, New York 11971 O ® fO ��`
Telephone /*.-
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE : , /F 19Y?
• OWNER NAME: ,
OWNER MAILING ADDRESS: 7),(0L4.4. 49,
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OWNER PROPERTY ADDRESS:
5-7
OWNER TELEPHONE NUMBER: 3)J_ ,cefji/
TAX MAP NO. : Section / Block \.J Lot A. /
CROSS STREET: �a-h-tyu
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool L New Existing
Residential j/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: // /Z ‘12-1-
LOCATION
1 _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:
Cler�
's- Office
DATE: APR 191989-
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