HomeMy WebLinkAboutCzartosieski -
y,
JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® � P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
® �� i�` Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1749-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CZARTOSIESKI, THEODORA
Mailing Address 1 P. O. BOX 781
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 51925 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3782
Tax Map No. section 63.00 block 5 lot 8.000
Cross Street TUCKERS LANE
Date Of Last Pump Out 0/00/00
Issue Date: 9/10/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I S
1-dam
OFFICE OF THE TOWN CLERK 'c0FOUI- -
Town of Southold CQG' Application No./74,79
Judith T. 'Terry, Town Clerk �` A.�"� =
Town Hall, 53095 Main Road �� ' $10.00 - Residential
P. 0. Box 1179 vs .* �`
$25.00 - Non-Residential
Southold, New York 11971 Ool.4, ��0�
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. //S/y
Fee $ /D, )
DATE 62/Ot � / /
OWNER NAME: cv50e4 (,�Ct1� foS/ESICI
OWNER MAILING ADDRESS: W(.0_ so, 78 /
o1 Ny / 197 /
OWNER PROPERTY ADDRESS: H.' .6l7D2 _get ,/ je2
oJD //Li )/ / /lr' 7 /
OWNER TELEPHONE NUMBER: ,�/G- 9
TAX MAP NO. : Section G 3 Block OLot v O
CROSS STREET: L E�Q.5
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool i/ New Existing
Residential v Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1 / 19 9 /
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.)
Signage of Applicant
RECEIVED BY:�
Tow Clerk' Office
RECEIVER
DATE:
SEP 091991
Town CletK FLOM
Al
01 0, CESSPOOL
x / 73`
.N 173
nRjSE TRAP
i
a% 0. i
Ili .
251
Et_.-,' , ,
exi$T„vF
‹-I- I ,y' 6 vie !
1 i •,
10
4
on,