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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK p rZ P.O. Box 1179
t cl' � Southold, New York 11971
REGISTRAR OF VITAL STATISTICSV® �� Fax (516) 765-1823
MARRIAGE OFFICER = .,` �* Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER ®,l FREEDOM OF INFORMATION OFFICERIlb!
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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. 3200-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner LEWENDOSKI, WILLIAM
Mailing Address 1 P. O. BOX 739
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3405 GRAND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5342
Tax Map No. section 107.00 block 1 lot 8.001
Cross Street KNOLLWOOD LANE
Issue Date: 5/19/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'0 "•i5.
OFFICE OF THE TOWN CLERK COFOU
Town of Southold CQG'_
�� Application No. oZ 00
Al_ AJudith T. Terry, Town Clerk '�
Town Hall, 53095 Main Road t ..G ' $10.00 - Residential
P. O. Box 1179 cry -'i ' z $25.00 - Non-Residential
Southold, New York 11971 0 '` ��`
'
Telephone ICA*: Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 4 1z
•
OWNER NAME: v S [
OWNER MAILING ADDRESS: 3 `t05- G, e n- Ado tr l3 v '
OWNER PROPERTY ADDRESS: -
OWNER TELEPHONE NUMBER: 576 `a-ct ? 5 `f •
TAX MAP NO. : Section /01 Block / Lot r, I
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
•
LOATION MAP: Must be attached hereto before permit may be issued.
` 11(16 -r14 . (Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
ktb 44,(7
Ng--e-44"--e4A_ct4-4-4:
---- Signature of Applicant •
RECEIVED BY:
Town Clerk's Office
DATE:
,