HomeMy WebLinkAboutWysocki (2) It
JUDITH T. TERRY wae
: Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
� Fax (516) 765-1823
MARRIAGE OFFICER O`
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Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3092-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WYSOCKI, WILLIAM JR.
Mailing Address 1 P. O. BOX 35
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 845 ORCHARD STREET
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3510
Tax Map No. section 25.00 block 2 lot 17.003
Cross Street VILLAGE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FFO
Town of Southold �� ^ CQG' Application No3° ??4v9,Judith T. Terry, Town Clerk
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Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cn ' ,4 z $25.00 - Non-Residential
Southold,
New York 11971 �O � , �0���`
Telephone _ 1 N e i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for •
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
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OWNER NAME: b/%Mi G��%,SC' air
OWNER MAILING ADDRESS: A / 9, l Aed s% Po BD x S'
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OWNER PROPERTY ADDRESS: 8 ,.5--( --Rehogb
OWNER TELEPHONE NUMBER: 5/Z® 3576
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TAX MAP NO. : Section .or:o & Block L Lot /7 6 b-S
CROSS STREET: V/ 09-6-
TYPE
/ // -6TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New X Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 97-
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, tä building and closest road.)
V-4447A110
Signature Applicant
RECEIVED BY:
Tow Clerk's Office
DATE: ( /Z ��
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