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Town Hall, 53095 Main Road
cam® ' P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1361-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LOMAGA, GEORGE
Mailing Address 1 BOX 1085
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 5800 WICKHAM AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8184
Tax Map No. section 140.00 block 2 lot 10.000
,Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
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Issue Date: 1/11/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'•I
OFFICE OF THE TOWN CLERK o�FFO '_
Town of Southold NQS :y '2 . Application No. /��7
Judith T. Terry, Town Clerk kc , y
�w=rs:' �G $10.00 - Residential
Town" Hall, 53095 Main Road � ��:��a �: ,.:�„�3
P. O. Box 1179 tri „:•; y^ i ; $25.00 - Non-Residential
Southold, New York 11971 p ® .t7 • ���,
Telephone _ .
igd
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
•
DATE /21/9/x1
OWNER NAME: G e o e Ge Lo "7, g •
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OWNER MAILING ADDRESS W hie ve - BOX /0 g
-- - - OWNER PROPERTY ,ADDRESS: , /IA-M, -
/9 1 -7-00K1 )(AY / qr)—.,
OWNER TELEPHONE NUMBER: (51t) -- r/ f y”
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: ////r/cP,'
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.)
Signat a of Applicant
RECEIVED BY: '- - - -
Town Clerk's Office
DATE: -
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