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JUDITH T. TERRY ; /+ Town Hall, 53095 Main Road
TOWN CLERK ® Fri P.O. Box 1179
ct' �� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS � y, w�� Fax (516) 765-1823
MARRIAGE OFFICER 0‘.`r •
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.05•••• Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3127-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DEERKOSKI, FELIX A.
Mailing Address 1 P. O. BOX 248
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2055 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8121
Tax Map No. section 107.00 block 8 lot 5.000
Cross Street WESTV I EW DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERKC3FULA-
Townown of Southold � CQ ' Application No(5/�y
Judith T. Terry, Town Clerk
om ' ,. �►:�
Town Hall, 53095 Main Road0 ". _ „ _ ' $10.00 - Residential
P. O. Box 1179 cry ' $25.00 - Non-Residential
Southold, New York 11971 O `� ''�' �•`�
Off',•'
Telephone 0 NW
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 9-a7/-
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OWNER NAME: Fe ik R . beerkosx/
OWNER MAILING ADDRESS: P.o. Bch v�f
OWNER PROPERTY ADDRESS: Or&nd - P --
OWNER TELEPHONE NUMBER: '76 ,17ft-c��j
TAX MAP NO. : Section /-Q Block d Lot• .7
CROSS STREET: V cs-j-vk& brisye- .
TYPE. OF .SYSTEM: Septic Tank V- New Existing
Cesspool New Existing
Residential 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.)
•
Signature of Applicant
RECEIVED BY:_ - - - - . __
Town Clerk's Office
DATE: .
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