HomeMy WebLinkAboutBarisic FOL 4,7-
JUDITH T.TERRY �•�� fir+ Town Hall, 53095 Main Road
TOWN CLERK ; cogi on ; P.O. Box 1179
pry Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER _ � � Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER --76:49 $ / Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3735-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BARISIC, ANNA E.
Mailing Address 1 P. O. BOX 154
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 NEW SUFFOLK ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5532
Tax Map No. section 117.00 block 5 lot 25.000
Cross Street GEORGE STREET
Issue Date: 12/02/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'J
! its III
OFFICE OF THE TOWN CLERK cOFour -
Town of Southold &,% • CQG Application No.37. 5
Judith T. Terry, Town Clerk
• Town Hall, 53095 Main Road i {� ' f":� � $10.00 - Residential
P. O. Box 1179 � #"' '' ;� '' ‘'
$25.00 - Non-Residential
Southold, New York 11971 O Telephone lo( , it*".***
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
far
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •/
DATE X.-6-1J 707 y7
Ait
OWNER NAME: i/I/ a Cc- ��
OWNER MAILING ADDRESS: O V ( S(
19;7,0
OWNER PROPERTY ADDRESS: Q3 _� -- - • '
•
OWNER TELEPHONE NUMBER: 5-16, 73 SC 5��'�
TAX MAP NO. : Section / / 7 Block Lot__ .5
CROSS STREET: eo rgr S/ree±
TYPE OF SYSTEM: Septic Tank �/ New Existing
Cesspool C/ New Existing 1�
Residential Non-Residential
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 Applicant
RECEIVED BY: ,
(
Town Clerk's Office
DATE: ,�__ _
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