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D,91 Town Hall, 53095 Main Road
P.O. Box 1179
��474 �� ;!i/ Southold, New York 11971
JUDITH =� �1r'! FAX(516)765-1823
T.TERRY
�` TELEPHONE(516)765-1801
TOWN CLERK
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. 1356-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner JAZOMBEK, BEN
Mailing Address 1 SOUND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8773
Tax Map No. section 121 .00 block 4 lot 2.000
Cross Street LAUREL LANE
Date Of Last Pump Out 0/00/00
Issue Date: 1/10/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III
OFFICE OF THE TOWN CLERK cWF�(,Y�''' {�
Town of Southold Q�VApplication No. 1351A
Judith T. Terry, Town 'Clerk '
Town Hall, 53095 Main Road $10.00 - Residential
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p. O. Box 1179 En VE Or , $25.00 - Non-Residential
Southold, New York 11971 O -® c•••''
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Telephone ®j •
(516) 765-1801
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation PermiterNo.
Fee $ /0 ) rp
•
DATE , I / 5 �
OWNER NAME: (a 4, 62"-- • • •
OWNER MAILING ADDRESS:
PROPERTY ADDRESS: • �� jP1
OWNER ,2
77
OWNER TELEPHONE NUMBER: q v S'- g 773
TAX MAP NO. : Section 121 Block ' Lot
CROSS STREET: "d t,e/Le j -j-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool a __ New / Existing__
Residential i Non-Residential
DATE OF PREVIOUS PUMP-OUT: -y-.
•
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.)
aLre of Applicant
RECEIVED BY: ,'/, ! ice, ��
own Clerk's •ff• e
DATE: //9/9,6
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