HomeMy WebLinkAboutChudzinski OFFICE OF THE TOWN CLERK , ' JI -
Town of Southold , OQ� C��
Judith T. Terry, Town Clerk
Town Hall, - 53095 Main Road
P. O. Box 1179 � g � ,
Southold, New York 11971
Telephone '414od 4;10
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 407 Residential X
Non-Residential
- Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Genevieve Chudzinski
OWNER MAILING ADDRESS: 5755 Depot Lane
Cutchoque, New York 11935
OWNER PROPERTY ADDRESS: 5755 Depot Lane
- Cutchoque, New York
OWNER TELEPHONE NUMBER: 516-734-6336
TAX MAP NO. : Section 96 ' Block 4 Lot 5
CROSS STREET: Route 48
TYPE OF SYSTEM: Septic Tank New Existing -
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Approx. 1985
Judith T. Terry
Southold Town Clerk
DATE: August 20, 1987 -
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ,�j��F�(�(•'-
Town of Southold ® *. CQG Application No. '4O
Judith T. Terry, Town Clerk � S
';�.- .. l Residential
Town Hall, 53095 Main Road ® _.
P. O. Box 1179 cn �� Non-Residential
474kS:c-Southold, New York 11971 �� �,4,„
�
Telephone 4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ to,OD
DATE ft-k) =c69
OWNER NAME: CX-NK 1/) E T4 �..� ,IV5-'. /
OWNER MAILING ADDRESS: 7` 3- � 7 4-4 hi E
l / 71° J�
OWNER PROPERTY ADDRESS: cE,/1 J l/E V Oa-7. 1 p mac' ,I
OWNER TELEPHONE NUMBER: 7 ‘ 134
TAX MAP NO. : Section 96 Block Lot
CROSS STREET: „
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
-- - DATE OF PREVIOUS PUMP-OUT: "- /9'4,5-
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 of Applican
RECEIVED BY: Cee/
Town£lerk' Office
RECEIVED
DATE:
AUG�, 2 0 1087
Town rlurlc Southold.
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