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ELIZABETH A.NEVILLE �� � 4*: Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER :=�i � �11, Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER �hl ,fr,. Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER _ ,����� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4153-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner BEDNOSKI, JOHN
Mailing Address 1 PO BOX 187
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 2080 HENRY'S LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 631-765-2727
Tax Map No. section 74.00 block 2 lot 1 .000
Cross Street SOUNDVIEW AVENUE
Issue Date: 7/23/02 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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A.OFFICE OF THE TOWN CLERK •CO F '
TOWN OFSOUTHOLD \) Application No. yi S
I LIZABETH A.NEVILLE,TOWN CLERK �•
$10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEW YORK 11971 ,' '$ $25.00 on-Residential
Telephone �7-14 .116•••
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(516) 765-1801 f ,.
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TOWN OF SOUTHOLD ., ,
SOUTHOLD WASTEWATER DISP .:' rit&i *fk ,
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APPLICATION • ;
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for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10.00
DATE 6/13/02
4
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OWNER NAME: JOHN BEDNOSKI
OWNER MAILING ADDRESS: p.o. BOX 187
PECONIC, NY 11958
OWNER PROPERTY ADDRESS : 2080 HENRY'S LANE
PECONIC, IIY 11958
OWNER TELEPHONE NUMBER: (631) 765-2727
TAX MAP NO. : Section 74 Block 02 Lot 01
CROSS STREET: SOUND VIEW AVE.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New X Existing
Residential X 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.)
At \ _
i. at r a of App ican
RECEIVED BY:
Town Clerk's Office
DATE: