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OFFICE OF THE TOWN CLERK ' cOFOCKe►"
Town of Southold
Judith T. Terry, Town Clerk � _ •:-
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971 O`- - 0�- •�
Telephone �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
•
Operation Permit No. 97 Residential XX
Non-Residential
Fee $ 10.00
Septic Cesspool XX
NAME OF OWNER: Michael Jaworecki
OWNER MAILING ADDRESS: P.O. Box 41
Orient, New York 11957
OWNER PROPERTY ADDRESS: 1740 Village Lane
Orient, New York
OWNER TELEPHONE NUMBER: 516-232-2541
TAX MAP NO. : Section 24 Block 2 Lot 1'8
CROSS STREET: Skippers Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XX New Existing XX
• Residential XX Non-Residential
•
DATE OF PREVIOUS PUMP-OUT: August 1986
•
•
Judith T. Ter
Southold Town Clerk
DATE: October 20, 1986
(TOWN SEAL) -
•
I.
OFFICE OF THE TOWN CLERK c��FMA,
Town of Southold % CQ� Application No.
Judith T. Terry, Town Clerk '
� �;��� � „�%) Residential
Town Hall, 53095 Main Road c 4
P. O. Box 1179 �' til : ' ',�` Non-Residential
uy
Southold, New York 11971
Telephone *04 0
t°
(516) 765-1801
RECEIVED TOWN OF SOUTHOLD
OCT 2 01986 SOUTHOLD WASTEWATER DISPOSAL DISTRICT
Trnw m 01,1rk Southold
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 91
Fee $ /U
DATE tD( 'Lo )c-60
OWNER NAME: -a,uoCil-SAL.l
OWNER MAILING ADDRESS: paO - (J p (5)C 4 1
0 1 4. 11 G. 3-7
OWNER PROPERTY ADDRESS: \ i D \J LaCict_ _ r"u" --- _
0 r�A.J2A.A_ — , 1 ) 9S--(7
OWNER TELEPHONE NUMBER: . D-- -'ta�j
TAX MAP NO. : Section `t' Block Lot t o
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool New Existing ✓
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: .S\g
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.)
o.eoceLf2-t.)6( .(1}0
Signature of Applicant c x
RECEIVED BY: 067xche , a-J
Townerk's Office
DATE: 02-6 ,. /96F67
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