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r� F.J`` Town Hall, 53095 Main Road
cb ‘;- P.O. Box 1179
j� 1,//r����®h� Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1252-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KURKOSKI, ZYGMUNT
Mailing Address 1 MIDDLE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 MIDDLE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-298-4252
Tax Map No. section 108.00 block 3 lot 7.000
Cross Street ELIJAH LANE
Date Of Last Pump Out 0/00/00
Issue Date: 9/26/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COFOI1.
Town of Southold Q - ea " Application No. 42.51-1-i
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10,00 - Residential
P. O. Box 1179 ` _
x -� $25,00 Non-Residential
Southold, New York 11971 p 6Z.
Telephone
Telephone �( -1\U
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
AUG 3 O 1919 OPERATION PERMIT
SO SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /d• '�
DATE
OWNER NAME: Z /G a'1 Ji(l' U"Cirlj S •
•
OWNER MAILING ADDRESS: 4//0 13/ G
OWNER PROPERTY ADDRESS: ��i//
OWNER TELEPHONE NUMBER: S7%
TAX MAP NO. : Section mg „3- '7 Block Lot
•CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7/j_2/p.-�
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.)
/
isnature of Applicant
RECEIVED BY: viatig0 ' z_c66—G sr
TbwirCI'erk's Office /
DATE: SEBA t 158g
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