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JUDITH T. TERRY 'CV Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Z =a ? Southold, New York 11971
IfsMARRIAGE OFFICER Fax (516) 765 1823
, � � 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. 1675-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ELAK, ALEC
Mailing Address 1 SOUTH HARBOR ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 SOUTH HARBOR ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3948
Tax Map No. section 75.00 block 7 lot 4.000
Cross Street BAYV I EW ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/29/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFI`CE 'OF THE TOWN CLERK 'S��FDCA �
Town of Southold Q C A lication No. 'S-
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Judith T. Terry, Town Clerk v :Y
I $10.00 - Residential
Town Hall, 53095 Main Road ci
cn �r� i:
P. O. Box 1179 xti � +�i � $25.00 - Non-Residential
Southold, New York 11971 O ® ' • .
Telephoneit I
(516) 765-1801
TOWN OF SOUTHOLD:
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. v
Fee $ /b0 A/14 �,y`,
DATE ; 1.. q �
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OWNER NAME: GG FA/2,-
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OWNER MAILING ADDRESS: AtfOre,ak IF&"
19' 7 /
OWNER PROPERTY ADDRESS: -61--ffd
,.� e`"i , q 2/
OWNER TELEPHONE NUMBER: 16S-3 (7� ?
TAX MAP NO. : Section Block Lot
CROSS STREET: j 1 { Il ! L 61.) /?J
/'
TYPE OF SYSTEM: Septic Tank, New Existing
Cesspool /i. New ? Existing
Residential -y Non-Residential
DATE OF PREVIOUS PUMP-OUT: /—
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
1
RECEIVED BY:
Town Clerk's Office
DATE:
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