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HomeMy WebLinkAboutBlasko ,1 g g#I1r1//9ii i�I /111®���1 0���t6 -- JUDITH T. TERRY Town Hall, 53095 Main Road TOWN CLERK P.O. Box 1179 REGISTRAR OF VITAL STATISTICS Eh Southold, New York 11971 MARRIAGE OFFICER Fax®z Fax (516) 765-1823 gy®1 0��, Telephone (516) 765-1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 3106-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New Existing X Name Of Owner BLASKO, BRUCE A. Mailing Address 1 23 MIDDLETON ROAD Mailing Address 2 City St Zip GREENPORT NY 11944-0000 Property Address 1 23 MIDDLETON ROAD Property Address 2 City St Zip GREENPORT NY 11944-0000 Owner Telephone No. 516-477-2990 Tax Map No. section 40.00 block 5 lot 9.000 Cross Street WILMARTH AVENUE Date Of Last Pump Out 0/00/00 Issue Date: 8/26/93 Judith T. Terry Southold Town Clerk (TOWN SEAL) 4 OFFICE OF THE TOWN CLERK sS\ FO(,( Town of Southold _ CQ Application No 76,6_ Judith T. Terry, Town Clerk � £�'" � -*%-t Town Hall, 53095 Main Road - $10.00 — Residential P. O. Box 1179 cr3 ;k $25.00 - Non-Residential Southold, New York 11971 ff` •`� Telephone _01 (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for 'OPERATION PERMIT SEPTIC TANK. or CESSPOOL Operation Permit No. . Fee $ • DATE A/AG. 1V-.` 19-93 OWNER NAME: OWNER MAILING ADDRESS: 23 MIPDL TOLD BIW • OWNER PROPERTY ADDRESS: SAT ME: OWNER TELEPHONE NUMBER: 4/1- (2_9c)0 TAX MAP NO. : Section Block Lot CROSS STREET: k,..; ILMwok 4 A-uE • • TYPE OF SYSTEM: Septic Tank New Existing Cesspool X New Existing X' Residential X Non-Residential DATE OF PREVIOUS PUMP-OUT: 1AL"( - 9 5 • 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: - .17;2C. S KoJ'�2=tee C A �3 y� 1r LE-Gkv RD . GP EE0Q Po kre--r- ?LY, l 194(IL VLLOb�NEJJ' Ft LDS Dc Wgs7 Cess paa ( Vo x �oPp 5I A ,Mc 1DtE761v RD _f F r ©z�tt -4, ti �