HomeMy WebLinkAboutBrashich ortiV JP*
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;x, Town Hall, 53095 Main Road
4 1` P.O. Box 1179
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__ �2, �• Southold, New York 11971
JUDITH T.TERRY ®� yrs' 0 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. 888-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BRASHICH, RADMILA
Mailing Address 1 BOX 623
Mailing Address 2
City St Zip NEW SUFFOLK NY 11952-0000
Property Address 1 143 FIFTH STREET
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-6235
Tax Map No. section 117.00 block 6 lot 8.000
Cross Street ORCHARD STREET
Date Of Last Pump Out 0/00/85
Issue Date: 10/11788 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
"
OFFICE OF THE TOWN CLERK C3\ Fair
Town of Southold - Application No. 8 ""
Judith T. Terry, Town Clerk r-- � ,
Town Hall, 53095 Main Road a ' `'7} U 1 Residential
DagrP. O. Box 1179 cn t. ,. i ` Non-Residential
Southold, New York 11971 ‘.1.-
Telephone
121 ��0�o•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /O•
DATE eti-t /7 /?9P
A
• OWNER NAME: 4-'91/ d 13( /3A)e-S611L- ze-
OWNER MAILING ADDRESS: /J01( •6, 3
New Fr-01.e, 1i. 0//l
OWNER PROPERTY ADDRESS: J/y3 ��Q--�'tc7 J �P1 p� /
!1` 1�6q/ V 1) F-Faer J'o p A �/ 9 1/76
OWNER TELEPHONE NUMBER: ur,G/i3Y-' S—
TAX MAP NO. : Section // 7 Block 4, Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ` Non-Residential
DATE OF PREVIOUS PUMP-OUT: /9?fr
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.)
•
4/C4.6e--;6‘
Signature of Applicant
RECEIVED BY• ,ty.
KC 'CO Z Jerk's ffice
DATE: ET 1 98Q
Town MR Soutliold
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