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OFFICE OF THE TOWN CLERK t FI! l p'LA
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Town of Southold �C�V� Olj�c.
Judith T. Terry, Town Clerk h_ •�
Town Hall, 53095 Main Road
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P. 0. Box 117 9 c� . �h. --
Southold, New York 11971 \ O °
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Telephone o ��
(516) 765-1801
TOWN OF SOUTHOLD .
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 5§4 9 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: John Kosloski
OWNER MAILING ADDRESS: RED 1, Box 85E
Mattituck, New York 11952 -
OWNER PROPERTY ADDRESS: 880 Deep Hole Drive
Mattituck, New York 11952
OWNER TELEPHONE NUMBER: 516-298-4233
TAX MAP NO. : Section 115 Block 12 Lot 13
CROSS STREET: New Suffolk Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: 8-31-87
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Judith T. Te
Southold Town Clerk
DATE: December 29, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �SOFO( r��=
Town of Southold Application�a'� Application No. ,SJS4
Judith T. Terry, Town Clerk • r/
Town Hall, 53095 Main Roae C Residential
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P. 0. Box 1179 cr' 3 � r Non-Residential
Southold, New York 11971
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Telephone y
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. S`/
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Fee $ /O,
DATE //7477
OWNER NAME: 7/4( /g5/ ds/ /'
OWNER MAILING ADDRESS: ) '/ �1 o k d,5
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OWNER PROPERTY ADDRESS:,,,,
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OWNER TELEPHONE NUMBER: (`,/`�/‘) o, -
TAX MAP NO. : Section //.5' Block /,,Z' Lot
CROSS STREET: /�'// J ,f d -I{
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing !/
Residential 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.)
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Si ure of Applicant
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RECEIVED BY: 4..71c,a(oCt... Q
Town Cl rk's Of ce
DATE: DEC 2 9 IN
Tnum Clerk Southold
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