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HomeMy WebLinkAboutWysocki a -'d I/ ,///II/,iiq Oielf 01. tl 16 e JUDITH T. TERRY z Town Hall, 53095 Main Road TOWN CLERK ® T , P.O. Box 1179 REGISTRAR OF VITAL STATISTICStda Southold, New York 11971 Fax (516) 765-1823 MARRIAGE OFFICER ® ®� • = --- 740), Net it 41 41 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. 3091-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner WYSOCKI, ANTONE J. JR. Mailing Address 1 P. O.BOX 29 Mailing Address 2 City St Zip CUTCHOGUE NY 11935-0000 Property Address 1 35260 MAIN ROAD Property Address 2 City St Zip CUTCHOGUE NY 11935-0000 Owner Telephone No. 516-734-6795 Tax Map No. section 97.00 block 2 lot 4.000 Cross Street BRIDGE LANE Date Of Last Pump Out 0/00/00 Issue Date: 8/17/93 Judith T. Terry Southold Town Clerk (TOWN SEAL) 1 , "I OFFICE OF THE TOWN CLERK 0° OA. 3© / Town of Southold t�� CQG'; Application No. Judith T. Terry, Town Clerk .e ; S_`, k: * Town Hall, 53095 Main Road %._ `_: ; ` $10.00 - Residential ,s p. O. Box 1179 �I', , Y �% $25.00 - Non-Residential Southold, New York 11971 O � �O� •�� Telephone _ ( �� (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for , OPERATION PERMIT - SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ • DATE- OWNER NAME: A i .A. O. ry e- ,[ Wysoct` h OWNER MAILING ADDRESS: CO, 8d566 4r-c/ rnAlto f-cL d a - oi..a. 4 iu_y . /•/gas-- OWNER PROPERTY ADDRESS: g S'a (" Q ry a N CC(4 ... 1'1..®5 6,e puV. /I73s� OWNER TELEPHONE NUMBER: 676 - 7341- 6 7 7i" , j TAX MAP NO. : Section 97 Block c Lot 4/ - CROSS STREET: ,gip - ----,6:1_,- ..:- TYPE_OFL;SYSTEM: -Septic -Tank- =- '" _. _-_New Existing Cesspool X. 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.) 1:3 it-/ PP ,C /,, � z(07, IF, , Si ture .f Applicant RECEIVED BY: - _ Town Clerk's Office ' - DATE: ' /5"-- z - -73—