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OFFICE OF THE TOWN CLERK S�FFO(,�
Town of Southold CSG
Judith T. Terry, Town Clerk _ ►
Town Hall, 53095 Main Road C2 3
P. 0. Box 1179 cn
Southold, New York 11971
TelephoneOlt
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 12 Residential XXX
Fee $ 10 . 00
Non-Residential
'
Septic Cesspool XXX
NAME OF OWNER: Marjorie Kui awski '
OWNER MAILING ADDRESS: 10 Sound Avenue
Greenport , New York 11944
OWNER PROPERTY ADDRESS: same
OWNER_ TELEPHONE NUMBER: 477-2111
TAX MAP NO. : Section ' 035 Block 1 Lot 20
1
I
CROSS STREET: Main Road (Rnn 25)
.> TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XXX New Existing XXX
Residential XXX Non-Residential -'
DATE OF- PREVIOUS PUMP-OUT: approx. 1 year
Judith T. Terry 47
Southold Town Clerk
DATE: August 15 , 1986
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 5�1'FF�(�
Town of Southold 0�� ��� Application No. la_
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road o ... y4y '4 I ResidentialLZ
P. 0. Box 1179v' = Non-Residential
Southold, New York 11971 O Y
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 0—
Fee $ f
DATE_
OWNER NAME: A--Y� 16r iv e-
OWNER MAILING ADDRESS: e. ,N V C K-(.,L �O
OWNER PROPERTY ADDRESS: '54L
OWNER TELEPHONE NUMBER: 4 7 7 - a 1 )
1
TAX MAP NO. : Section (�`� Blocki Lot a Q
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ ew Existing /
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: W7 <j .a
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.)
Si natu plicant
RECEIVED BY:
o CI k's Of ice
DAT E: