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JUDITH T. TERRY Z Town Hall, 53095 Main Road
TOWN CLERK : v T P.O. Box 1179
if) Southold, New York 11971
REGISTRAR OF VITAL STATISTICS Fax�� Fax (516) 765-1823
MARRIAGE OFFICER '`® �® ��
/ Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ' i/ •/I�•I
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3194-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KOROLESKI, ROSE
Mailing Address 1 172 SOUND AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 172 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8266
Tax Map No. section 112.00 block 1 lot 9.000
Cross Street ALDRICH LANE
Issue Date: 4/20/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
f
OFFICE OF THE TOWN CLERK c1FOC,r -
Town of Southold ��� t . KCQG•� Application No. 5
Judith T. Terry, Town Clerk . , m
$10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 tri _ 3 $25.00 - Non-Residential
Southold, New York 11971 O0 �0� /•�`�
Telephone .( '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
_„ , F.tk''e'",,i A n CON
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /•
DATE g-- 7 - /9'947
•
OWNER NAME: S a/ c =S/<
OWNER MAILING ADDRESS: 1$01 , ^)(...70c;/ r w�nu
/471-77—cr—OC-4. I y
OWNER PrtOP.ErtT\ A DRESS: 7 ._ ./ - •:-
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OWNER TELEPHONE NUMBER: 557 — o?9S'-- ??e6
TAX MAP NO. : Section /,a- Block ( Lot
CROSS STREET: ,/'c/,C/ ,IaY7 e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool v New Existing
Residential 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.)
41( /IF
I 6C442-- 611%46
Si•nature of Ap•licant
RECEIVED BY: ,, (})/a41-'
Town Clerk's Office
DATE: ��
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