HomeMy WebLinkAboutBajek OFFICE OF THE TOWN CLERK • ���Y `,'
Town of Southold
Judith T. Terry, Town Clerk S4� '" �
Town Hall, 53095 Main Road ;.
P. O. Box 1179 \t� ,.
Southold, New York 11971 Q ® T`_: � •�
Telephone _ ®1 'A
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 134 Residential x
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Mary Bajek
OWNER MAILING ADDRESS: P.O. Boxc476
Cutchogue, New York 11935
OWNER PROPERTY ADDRESS: Pequash Avenue
Cutchogue, New York
OWNER TELEPHONE NUMBER: 516-734-5150
TAX MAP NO. : Section 103 Block 7 Lot 30
CROSS STREET: Main Road (State Route 25)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool x New Existing x
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: September 9. 1986
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Judith T. Terry
Southold Town Clerk
DATE: November 7, 1986
(TOWN SEAL) -
OFFICE OF THE TOWN CLERK CO HU -
Town of Southold �® �QG' Application No. /3V
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road �:; ) Residential
P. O. Box 1179 tomoi ; Non-Residential
Southold, New -York 11971 01471.?:,
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Telephone
(516) 765-1801 �I
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /
Fee $ / Q a d
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DATE ///
OWNER NAME: FLS
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OWNER MAILING ADDRESS:Pi0 w
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OWNER PROPERTY ADDRESS: _
OWNER TELEPHONE NUMBER: fI 1 ik® / ca
TAX MAP NO. : Section /'O Block 7 Lot C3 V
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool � � New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: j R '
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.)
Signatu e of AAppilfcant
'RECEIVED cz,„..„0 �y
R.„,thown lerk's Office -
DATE: mev ® ot
Town C r@t Suthcald