HomeMy WebLinkAboutBagenski dr _{ ,
Town Hall, 53095 Main Road•
f' ' < .��� P.O. Box 1179
� � Southold, New York 11971
i1131 1°
JUDITH T.TERRY ,••0°
FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1191-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BAGENSKI, CONRAD
Mailing Address 1 BOX 716
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-4809
Tax Map No. section 108.00 block 3 lot 9.000
Cross Street ELIJAHS LANE
Date Of Last Pump Out 0/00/00
Issue Date: 7/20/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 8c0FO(,('��=
Town of Southold % CQG Application No. 1/ 97'
Judith T. Terry, Town Clerk ®� ` Residential
Town Hall, 53095 Main Road 8 P :- _. - ,(
P. 0. Box 1179 cr3 ?* i Non-Residential
Southold, New York 11971426."7i :'*0/
O��'`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /(: IOD
DATE 6 -- /D —
OWNER NAME: (1...,e-M-4‘/
OWNER MAILING ADDRESS: (h42,4"...;;7 Prj4/ 7 , .
&If 7/(
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: _ 9?- 2/,k0(7
• TAX MAP NO. : Section /0g" Block �j Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential k Non-Residential
DATE OF PREVIOUS PUMP-OUT: /t—
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.)
Ci ., S ..3-f'�
Signature�f Applicant
RECEIVED BY:�p�,
Town Clerk Office
DATE:
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