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Town Hall, 53095 Main Road
' " P.O. Box 1179
l"fr_® Southold, New York 11971
JUDITH T.TERRY ®� �'.l��, FAX(516)765-1823
TOWN CLERK % .iz%i��`� TELEPHONE(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. 1323-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
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 CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6633
Tax Map No. section 1 .36 block 1 lot 24, /
Cross Street OAK STREET
Date Of Last Pump Out 1/01/64
Issue Date: 11/29/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'c�vFFO(,��
Town of Southold �y -_. C'QG� - Application No./ 3 3
Judith T. Terry, Town Clerk
4 ?:' . .t 1 $10.00 Residential
Town Hall, 53095 Main Road z•, YS
P. O. Box 1179cf3 ":: #_; �4. ' i ; $25.00 - Non-Residential
Southold, New York 11971 O1901 -0-.1"
l " �
Telephone _
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. E j
Fee $ 1/2., Dl7
•
DATE .2Z /261
OWNER NAME: To 6e rt
OWNER MAILING ADDRESS: Fd ( 9Q 6'
e � g a e ,' // '93. -
OWNER PROPERTY ADDRESS: , - N- t06`D r L
OWNER TELEPHONE NUMBER: 7 3 --Z6 33
TAX MAP NO. : Section /36 Block / Lot a9
CROSS STREET: QA k St re e)/""
TYPE OF SYSTEM: Septic Tank ✓ New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: / 9cs 1/
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.)
X4414f9f &19401'4'4.
Signa a of Applicant
RECEIVED BY: (40/ -1 _/:%
n C erk's •ffice
DATE: ///n?.?/8/
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