HomeMy WebLinkAboutBorkowski (2) JUDITH T.TERRY '"' :tib Town Hall
® , .. .. ,53095 Main Road
TOWN CLERK c = F; ' g P.O.Box 1179 s t
REGISTRAR OF VITAL STATISTICS ® 3 kV 0 Southold,New York 11971
MARRIAGE OFFICER 4b 41P � Fax(516)765-1823
RECORDS MANAGEMENT OFFICER � It, 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. 3408-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner BORKOWSKI, MICHAEL AND JOAN
Mailing Address 1 11080 SOUND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 11080 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-1015
Tax Map No. section 142.00 block 1 lot 18.000
Cross Street WALNUT AVENUE
Issue Date: 11/24/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK . IFO����' 11''
Town of Southold 1 ��% 4 Application No."Td e
Judith T. Terry, Town Clerk . 4-1 ..
Town Hall, 53095 Main Road N x ..4 $10.00 - Residential dLI
P. O. Box 1179 u' " ;' $25.00 - Non-Residential
Southold, New York 11971 O :'' oC�,`,,
® 4 0•
Telephone y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 1:0
DATE 101 l 1 195
• d
-3-
OWNER NAME: Ifld €-1 °l'" -3-ban o r K Du-) Sk-A
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDRESS : 1 lDab • dr) 0 Ate...40(1e"
fn6,F+a c n ) 19 Sd
OWNER TELEPHONE NUMBER: a 9 3 10 IS
TAX MAP NO. : Section M Block / Lot /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool a/ New Existing17 ,
Residential V 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.)
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())1/4.igNi
Signature of Applicant
RECEIVED BY: 4%10. 41,
4
ow i k's Office
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DATE:
kiareED
NOV 31995
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