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JUDITH T.TERRY ; ® r'" SrA Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
y Southold,New York 11971
REGISTRAR OF VITAL STATISTICS 'p` _ 4 �1 Fax(516)765-1823
MARRIAGE OFFICER "`'`
RECORDS MANAGEMENT OFFICER = 1.1 19,10 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. 3332-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DEROSKI, ROBERT J.
Mailing Address 1 P. O. BOX 906
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 HARBOR LANE
Property Address 2
City St Zip CUTCHGOUE NY 11935-0000
Owner Telephone No. 516-734-6633
Tax Map No. section 136.00 block 1 lot 22.000
Cross Street OAK STREET
Issue Date: 5/16/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
0F FICE OF THE TOWN CLERK cl\FFO( r�'-
Town of Southold &� CQG',, - Application No. 333;2-
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road -< $10.00 - Residential
p. O. Box 1179 to ;' $25.00 - Non-Residential
Southold, New York 11971 O *1`,
Telephone 70 * •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
• for
OPERATION PERMIT
- SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ (6 .
DATE I2,.
OWNER NAME: 66eb- t f . d'6 .s
OWNER MAILING ADDRESS: TO °R 6.•/- 9 0 G
,
OWNER PROPERTY ADDRESS:
-II A-,,4 - 44-A1.e Z- 6, �' 'ate.e.
OWNER TELEPHONE NUMBER: 73 9 - 'j 5'
TAX MAP NO. : Section / 36 Block I Lot 2 a.
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential 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.)
2-ad/ 0
Signa/ o Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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