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JUDITH T. TERRY ti Town Hall, 53095 Main Road
TOWN CLERK tp
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS A Southold, New York 11971
MARRIAGE OFFICER
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Fax (516) 765-1823
4,) �� �!' Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3045-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LASOTA, WIESLAW AND ANNE
Mailing Address 1 360 LESLIE ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 360 LESLIE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7642
Tax Map No. section 97.00 block 9 lot 7.000
Cross Street SKUNK LANE
Date Of Last Pump Out 0/00/00
Issue Date: 6/28/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK . OMA' `�
Town of Southold � CQ = Application No.
Judith T. Terry, Town Clerk . " ;
Town Hall, 53095 Main Road } $10.00 - Residential
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p. O. Box 1179 Ctri =< �� 'fir ` $25.00 - Non-Residential
Southold, New York 11971 *$
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Telephone 1 `it
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 , 9752�
DATE I/5
OWNER NAME: LU l eS 10-(4) `1— 11fVne LAO"Ta
OWNER MAILING ADDRESS: :3 (00 _. LESS LIZ. le0/17�
CLL-L-,.O9 N Y a3 '
-- OWNER PROPERTY ADDRESS: -S ftn a-5 cJ
OWNER TELEPHONE NUMBER: ( 341 (764/
TAX MAP NO. : Section 4g17 Block i!�j Lot cL
CROSS STREET: 5U1L
TYPE OP SYSTEM: Septic Tank v New Existing_
Cesspool ✓ New Existing I/
Residential 1/ 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.)
aitik9 _ /a)4&'
Signature of Applicant
RECEIVED- BY:
Town Clerk's Office
DATE: •-
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