HomeMy WebLinkAboutBialeski 110.11
kt35 VA
Town Hall, 53095 Main Road
kg34‘r P.O. Box 1179
Ii! Southold, New York 11971
JUDITH T.TERRY ` �.1 FAX(516)7654823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1373-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BIALESKI, FELIX
Mailing Address 1 BOX 951
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 WESTVIEW DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4037
Tax Map No. section 107.00 block 8 lot 6.000
Cross Street GRAND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 1/31/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK , �c,\FFO(,r°--
Town of Southold v� ,, ..� �Cr&— Application No. /3-3
Judith T. Terry, Town Clerk • '=�` Kms; -
Town Hall, 53095 Main Road a .- `-. - $10.00 Residential ��
P. O. Box 1179 to -"0, ' 41 h�i ; $25.00 - Non-Residential
Southold, New York 11971 O ® •°= ':KOC,-•�`
Telephone 4e ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ ,'Q•,cb
•
DATE / 2/,�-,' 2)
OWNER NAME: / ,1 Al '
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OWNER MAILING ADDRESS: —_ �_ _1 �,
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cdam. —li is -'' -
OWNER PROPERTY ADDRESS: , ( ..4y' —_
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OWNER TELEPHONE NUMBER: ,E/ k_ 9g– y� d
TAX MAP NO. : Section I 0 – Block - g Lot
CROSS STREET: .L� /� Jam,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool Y---- New Existing ' >(
Residential k Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7,
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.)
/; /
Si•nature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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