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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS r .�` Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
v4i rm.,' 1%4G I�! Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1847-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KUDLINSKI, EDITH
Mailing Address 1 301 CHAMPLIN PLACE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 301 CHAMPLIN PLACE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-1177-0851
Tax Map No. section 34.00 block 3 lot 39.000
Cross Street STERLING PLACE
Date Of Last Pump Out 0/00/00
Issue Date: 2/13/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK e5�FFU `- p/(
Town of Southold Q� Application No. /a 7
Judith T. Terry, Town Clerk 7 � %'\ $10.00 - Residential
Town Hall, 53095 Main Road 1=
p. O. Box 1179 `v' '" '' '
., � $25.00 - Non-Residential
Southold, New York 11971
Telephone •
( '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
.APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
ed-€241-1 i DATE
OWNER NAME: Ver,15664940:e-
AzITIALYAIAS/t.-/
OWNER MAILING ADDRESS: tZ:3/ C /2/ L//cO
(3/Q_,/ - "9(/)61,"
OWNER PROPERTY ADDRESS:
• OWNER TELEPHONE NUMBER: ,5"--/-6, -%. 2 7 -q -7
TAX MAP NO. : Section '� Block 3 Lot c y
CROSS STREET:
TYPE `OF SYSTEM: Septic Tank New Existing
Cesspool New Existing >< •
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1 91-
LOCATION
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.)
• 0
E-11-1 at. / / e
Signature of Applicant
"7/2R7S; ,
RECEIVED'BYb(): Com,,,,
Town Clerk's Office I w ®
DATE: FEB 13•
7QC, - -
Town Clerk outliord