HomeMy WebLinkAboutBerkoski (2) Town Hall, 53095 Main Road
I N- $1 P.O. Box 1179
®1 0 Ili ��� Southold, New York 11971
JUDITH T.TERRY _����„�,r0 TELEPHONE
TOWN CLERK (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. 639-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner BERKOSKI , EDWARD AND TESSIE
Mailing Address 1 PIKE STREET AND MARY ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 PIKE STREET AND MARY ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4399
Tax Map No. section 140. 00 block 2 lot 44. 000
Cross Street CORNER LOT - PIKE ST & MARY RD
Date Of Last Pump Out 0/00/00
Issue Date: 3/07/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c�VFFDle^•
Town of Southold �� mss;- .,"j Application No. 3?
Judith T. Terry, Town Clerk kx ' TtI,N '''
Town Hall, 53095 Main Road , T` `'5 . ) Residential Yi�
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P. 0. Box 1179 cn :`, N*4; �; Non-Residential
Southold, New York 11971 O ' ;; - �`
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Telephone '40
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / d , hii
DATE yrff
OWNER NAME: Afzd.4 v--„i7 / /��5" Q, J c' )- no 5 /1" ( A
OWNER MAILING ADDRESS: Jt '_/1 V 977 d- 44 . frd
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OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: � .7 ?— 14-3 yr
TAX MAP NO. : Section ( / d Block 1/ Lot /I
CROSS STREET: P ,7r ,e ,- 1 A 7 Rd
TYPE OF SYSTEM: Septic Tank 1/ New Existing
Cesspool L/ New Existing 1--------
Residential
lResidential Non-Residential
- DATE OF PREVIOUS PUMP-OUT: 7 /y . ,k1
LOCATION MAP: Must be attached hereto bef re permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
4
71
S'g ture of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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61/1
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