HomeMy WebLinkAboutCharkow c3,
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Town Hall, 53095 Main Road
" ��`' P.O. Box 1179
- 41j. 1 ," Southold, New York 11971
JUDITH T.TERRY a..,iLXii1765-1823
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. 973-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CHARKOW, HARRY G.
Mailing Address 1 P. O. BOX 215
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 WESTPHALIA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8153
Tax Map No. section 141 .00 block 3 lot 21 .000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 1/09/89 Judith T. Terry
Southold Town Clerk
(TOWN SEALI
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OFFICE OF THE TOWN CLERK SFpte�'= n
Town of Southold �� CQA , Application No. 973
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Judith T. Terry, Town Clerk � ,, � - �. �►
Town Hall, 53095 Main Road
.G 1 Residential
P. O. Box 1179 = ;'' �; Non-Residential
Southold, New York 11971 O .
Telephone _ . _ - 1 '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ it)
DATE Z=, j5 ?F�
OWNER NAME: T74� k y G._ Ge
OWNER MAILING ADDRESS: ,_ 66 X c2 /
Ynfpr ire.C��sL /V. Y. / 7 -5--
OWNER
SOWNER PROPERTY ADDRESS: ,f�-. ��
OWNER TELEPHONE NUMBER: c/C -- 9' —
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TAX MAP NO. : Section P"T>/ Block 3 Lot c>, -
CROSS
, -CROSS STREET: ft- 1/
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: \ni ,4,9 f ? ?
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.)
d
ignature of Applicant
RECEIVED BY: c..6Le-
mcT570 erk's O fice
DATE: r, t.e
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