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HomeMy WebLinkAboutWidirstky //el, �� JUDITH T.TERRY Ott _ 1 Town Hall, 53095 Main Road TOWN CLERK ; y P.O. Box 1179 r �� Southold,New York 11971 REGISTRAR OF VITAL STATISTICS o �**/� Fax(516) 765-1823 MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER �.( ,x,� �►a���� Fax (516) 765-1800 FREEDOM OF INFORMATION OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3449-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner WIDIRSTKY, DARLENE LUDING Mailing Address 1 P. O. BOX 671 Mailing Address 2 City St Zip SOUTHOLD NY 11971-0000 Property Address 1 250 KORN ROAD Property Address 2 City St Zip SOUTHOLD NY 11971-0000 Owner Telephone No. 516-765-1295 Tax Map No. section 64.00 block 2 lot 29.001 Cross Street COTTAGE PLACE/FOUNDERS PATH Issue Date: 3/21/96 Judith T. Terry Southold Town Clerk (TOWN SEAL) O ,`FF OF THE TOWN CLERK gCSFOCA-„- "7 Town of Southold 0 CQG Application No.. ' Judith T. Terry, Town Clerk ��,� Town Hall, 53095 Main Road - 1 $10.00 - Residential P. O. Box 1179 ;' $25.00 - Non-Residential • Southold, New York 11971 ��t • Telephone o.� * ‘gee ' (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ • • DATE 3//cc-/? OWNER NAME: - t_ L2 ( / 7 (/ OWNER MAILING ADDRESS: \ 6,7 -SJ t-Wh© Id /J - 1177 ( OWNER PROPERTY ADDRESS: 6 2At,) i/D S0 �7- 0� �, , q7 / OWNER TELEPHONE NUMBER: d6 -76 S-/aq5 • TAX MAP NO. : Section (2 Block Lot &`7, CROSS STREET: C ' ?/-e' - (4)-5g TYPE OF SYSTEM: Septic Tank New Existing Cesspool c/ New Existing o� Residential 1/ Non-Residential 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.) X11 Signature of A elican RECEIVED BY: AL W-6C-)L-z...-t.L Town Clerk's fice DATE: '�// cr/`fN (d)cmp,,,p e°1 r 6c:hrEe) l� ,