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JUDITH T.TERRY �� _� y1 Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
r>7 1 Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O
�� � Fax(516) 765-1823
MARRIAGE OFFICER 4, „���i� Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICERi[ �`
FREEDOM OF INFORMATION OFFICER �,
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3486-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MAVROVIC, JOHN
Mailing Address 1 151-72 21ST AVENUE
Mailing Address 2
City St Zip WHITESTONE NY 11357-0000
Property Address 1 50930 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 718-862-4542
Tax Map No. section 70.00 block 2 lot 9.000
Cross Street JOCKEY CREEK DRIVE
Issue Date: 7/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'OFFICE OF THE TOWN CLERK �FFU
Town of Southold , 0�%� �Q Application No.3 Z ba
Judith T. Terry, Town Clerk - .
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 to ;' $25.00 - Non-Residential
Southold, New York 11971 0 ',`,
Telephone ... * �� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /CJS 6
DATE �
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OWNER NAME: ;/ /4-1 cm 4 df2Vf
OWNER MAILING ADDRESS: ,d/-'7,2.. ( Ates
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OWNER PROPERTY ADDRESS:41---(7 /i(4-/ cez-
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OWNER TELEPHONE NUMBER: 7/ et- 2--
TAX MAP NO. : Section 7D Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic.T,ank ;`, New y- Existing
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Cesspool New /- Existing
Residential 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.)
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