HomeMy WebLinkAboutZebroski 111'1®cj�"��o� N.
$� Town Hall, 53095 Main Road
�® //\ P.O. Box 1179
® •��® r� Southold, New York 11971
JUDITH T.TERRY "'"----......"00"1 ATELEPHONE
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. 651-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner ZEBROSKI , WILLIAM S. JR.
Mailing Address 1 200 GARDINERS LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 200 GARDINERS LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2989
Tax Map No. section 70 . 00 block 8 lot 13 . 000
Cross Street PINE NECK ROAD
Date Of Last Pump Out 0/00/00
/5/
Issue Date: - 3/16/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK CAW FO/
Town of Southold ;s C
�� Q ' Application No. CS/
Judith T. Terry, Town Clerk !It; ..;„A�') Residential
Town Hall, 53095 Main Road 8 -
P. O. Box 1179 i � Non-Residential
Southold, New York 11971 •
06� , ��`
Telephone Y► '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. - - -
Fee $
- DATE - ki fflt" ./ t - /
OWNER NAME: LA -vd 5 Z✓�3 i ,5-A,-; (TT1(
OWNER MAILING ADDRESS: , 0 kre
q_ \
OWNER PROPERTY ADDRESS: - 5
OWNER TELEPHONE NUMBER: 76", r
TAX MAP NO. : Section `26 Block Lot �3
CROSS STREET: 47,-c ke-c4-.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - 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.)
Signature o Applic
RECEIVED BY: _
Town Clerk's Office
DATE:
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