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JUDITH T.TERRY � '� Town Hall, 53095 Main Road
TOWN CLERK a P.O. Box 1179
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w i Southold,New York 11971
REGISTRAR OF VITAL STATISTICS � y l���/, Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER
MARRIAGE OFFICER � `�® �� Fax
(516) 765-1800
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FREEDOM OF INFORMATION OFFICER ,,�g.� ��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3528-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner DWORKOWITZ, ALAN AND BARBARA
Mailing Address 1 595 WEST END AVENUE
Mailing Address 2
City St Zip NEW YORK NY 10024-0000
Property Address 1 4225 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 212-724-7963
Tax Map No. section 137.00 block 2 lot 17.000
Cross Street STILLWATER AVENUE
Issue Date: 10/17/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.
OFFICE OF THE TOWN CLERK � .c31HU.�'=
Town of Southold , 0�� CQG=� Application No.�- OC
Judith T. Terry, Town Clerk . ;•,
Town Hall,,:53095..Main Road :,v' $10.00 - Residential
• p. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971
Telephone _
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Feet/ $ ' ��,<q.,•
DATE
OWNER NAME: /(440/1 -� P ai►a-�(J o o I�i
,OWNER MAILING ADDRESS: '�S--- (, :
too 2-1
OWNER PROPERTY ADDRESS:
cAyf 14(
'OWNER TELEPHONE NUMBER: (1....f ?� `724-17k,
TAX MAP NO. : Section ( 1 Block Lot /7
CROSS STREET: S41 tiu1
TYPE OF SYSTEM: Septic Tank , ., New Existing
,•„
,:'• Cesspool New Existing
• Residential c/ 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.)
• _f
Signature of Applicant
RECEIVED BY: .` , •.•3,,--,--- _. _______._ ,_
FlibEnGk'S Office
DATE:
OCT 171996
•
Southold Town Clerk
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