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JUDITH T. TERRY t� Town Hall, 53095 Main Road
v P.O. Box 1179
TOWN CLERK r,
REGISTRAR OF VITAL STATISTICS g93 .�`' Southold, New York 11971
MARRIAGE OFFICER r=�j z, Fax (516) 765-1823
®" 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. 1854-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LESKODY, STEPHEN F.
Mailing Address 1 1455 BEEBE DRIVE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1455 BEEBE DRIVE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5419
Tax Map No. section 103.00 block 4 lot 2.000
Cross Street MOOSE TRAIL
Date Of Last Pump Out 0/00/00
Issue Date: 3/04/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK FO rsy
Town of Southold �� CQG' Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a V t_.-4 ' $10.00 - Residential
p. O. Box 1179- `' $25.00 - Non-Residential
Southold, New York 119710�;� 0"/
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Telephone �/.( *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. •
Fee $
DATE
OWNER NAME: 5 r fN /•
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OWNER MAILING ADDRESS: t3I`tE h IE p is t (• E-
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OWNER PROPERTY ADDRESS:
S4 /v
OWNER TELEPHONE NUMBER: /73 5-3//i
TAX MAP NO. : Section Block Lot
`) CROSS, STREET:
TYPE ,OF-SYSTEM: Septic Tank New Existing
Cesspool '\ New Existing �(
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
1; 7 s (.ci /
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.)
441-"Siji6e7egnature
of pplicant
RECEIVED B Y: . M-Lik_ata912.
Office Town Clek's Office
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DATE: ���(�2--- - -� -- - --- -
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