HomeMy WebLinkAboutBerkoski = y = ;' Town Hall, 53095 Main Road
w- �� P.O. Box 1179
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__ '� Southold, New York 11971
JUDITH T.TERRY =-�- 0,,,,,,A X11° 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. 1008-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BERKOSKI, ANTOINETTE
Mailing Address 1 RR 3, 43545 MAIN ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 43545 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3256
Tax Map No. section 75.00 block 1 lot 19.000
Cross Street WELLS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 2/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
i/`
OFFICE OF THE TOWN CLERK
Town of Southold C Application No. 0 O
Judith T. Terry, Town Clerk .: „._, y \
Town Hall, 53095 Main Road a :, Residential
P. O. Box 1179
. . Non-Residential
Southold, New York 11971 OO �0*�`
Telephone = .( � '.
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
•
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE ° /� 1
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OWNER NAME: A ;/? it444/
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OWNER MAILING ADDRESS: 7074 ilArj 'RA,.
0o 0) ( A Ay //, 7i
OWNER PROPERTY ADDRESS:
66'61 el-
OWNER TELEPHONE NUMBER: 65��
TAX MAP NO. : Section .75 Block / Lot / 7
CROSS STREET: ,GJe /S /e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New ExistingOVele ./0 e fri
Residential 9O Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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 a of Applicant
RECEIVED BY: i
ifTo Clerk's Office
DATE: � 7 r �
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