HomeMy WebLinkAboutZipkas Town Hall, 53095 Main Road
� ,: P.O. Box 1179
`` Southold, New York 11971
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JUDITH T.TERRY ,0 FAX(516)765-1823
��� TELEPHONE(516)765-1801
TOWN CLERK
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. 1301-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ZIPKAS, MARY
Mailing Address 1 P. O. BOX 222
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-2096
Tax Map No. section 45.00 block s—#— lot y 7
Cross Street MOOR ES LANE
Date Of Last Pump Out 0/00/74
Issue Date: 11/13/89 Judith T., Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK .0�����..'=
Town of Southold _ Gam, Application No. /30/
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road . .)1 -4;1
}`� •,~ ;ir I $10.00 - Residential t '
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P. O. Box 1179 En 4 u t; , $25.00 - Non-Residential
Southold, New York 11971
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Telephone 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /1/
•
OWNER NAME: VV1 a NI((/ 7 / P S •
OWNER MAILING ADDRESS: r , O2 ,
--) -h J
OWNER PROPERTY ADDRESS: �` L;� tit /R
•OWNER TELEPHONE NUMBER: ' --
TAX MAP NO. : Section Block S` Lot 1
CROSS STREET: 7),-21
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: l q 7
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.)
ig^mature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
QL, NO),eSS To
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