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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK Z1 p T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
�� Southold, New York 11971
MARRIAGE OFFICER , Fax (516) 765-1823
�,y �1� � 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, 3185-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner LUKERT, WILLIAM AND JEANETTE
Mailing Address 1 P. O. BOX 1041
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1320 NEW SUFFOLK ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5899 •
Tax Map No. section 109.00 block 6 lot 11 .000
Cross Street CEDAR'S ROAD
Issue Date: 3/16/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
r
OFFICE OF THE TOWN CLERK SUFFO(,(�'= 3,'`S—
• Town of Southold � CQ Application No.
Judith T. Terry, Town Clerk
$y�.,,.. _.-moi•
Town Hall, 53095 Main Road < $10.00 - Residential
P. O. Box 1179 cn � y �` $25.00 - Non-Residential
Southold, New York 11971 O R Vii`'" '` " $
Telephone
Telephone 1I .* y►�� '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
AP!"1...irGT:0N
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ d/•0
• DATE JAS/
OWNER NAME: GJ/cuain 4 --1;4vETTE &E :
OWNER MAILING ADDRESS: /?,9. ,sok /D'//
C'i7 1 uL -//73s'
- -OWNER PROPERTY ADDRESS: J3 LO /4I„/ �il,e'FatIc ,e
Cum tf,wpE , �/Y- //93 t'
OWNER TELEPHONE NUMBER: 73V - ,5-l99
TAX MAP NO. : Section /69 Block G Lot //
CROSS STREET: &A,92.. ./s- 'o,i o
TYPE OF SYSTEM: Septic Tank New - Existing
Cesspool L New Existing G/
Residential t/ Non-Residential
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.)
(4/16-i:!Xe7.eiL
Signature of Applicant
RECEIVED BY:
Town Clerk's Office •
DATE:
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