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c ) F-Tira Town Hall, 53095 Main Road
gr6 % P.O. Box 1179
�� ,!� Southold, New York 11971
JUDITH T.TERRY op
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. 1437-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LUKOSVICUS, EDWARD A.
Mailing Address 1 565 SOUTH HARBOR ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 565 SOUTH HARBOR ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1580
Tax Map No. section 75.00 block 4 lot 1 .000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/04/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3�JFF�(��'`
Town of Southold O�� C'�G•• Application No. /4/3 7
Judith T. Terry, Town Clerk 451 x,
Town Hall, 53095 Main Road '�;fi�; :� I $10.00 - Residential
P. 0. Box 1179 ms
$25.00 - Non-Residential
Southold, New York 11971 PY. : ;,:(1-41 • •
Telephone OI "
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 d od 0
DATE 'Va/9v
OWNER NAME: 6.bivA2v 044/675 ✓/ Gl.{s •
OWNER MAILING ADDRESS: .S`-‘5" Sock-T/2i /,49Q.QOa' /'I
Sou // r7l
OWNER PROPERTY ADDRESS : 5Oa)e_ -
OWNER TELEPHONE NUMBER: 7‘5-45-E-‘)
- 7,5'- '�—
TAX MAP NO. : Section Block Lot
CROSS STREET: /1 /0✓
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT ?-f c/✓6-c c1 /OK,2 oco ) 626CO/2bS
o f7716 1366 Ye /NF,- L0n5 F.(C,v) yap 4-777,175 oP 4J - eq,n,' o cu-�--
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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EDWARD A.LUKOSVICUS
565 S HARBOR RD.
SOUTHOLD,NY 11971 \'