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JUDITH T. TERRY ` , Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK ®
REGISTRAR OF VITAL STATISTICS r o .� Southold, New York 11971
MARRIAGE OFFICER® ,;� Fax (516) 765-1823
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. 1924-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MAZGULSKI, RICHARD AND JOANNE
Mailing Address 1 380 TUTHILL ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 380 TUTHILL ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4663
Tax Map No. section 55.00 block 3 lot 19.000
Cross Street LONG CREEK DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 6/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN'CLERKJ 1 /�
Town of Southold , ckS -. CQ Application No./?Q
Judith T. Terry, Town Cl erk w �+ •
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 c./.3_ $25.00 - Non-Residential
Southold, New York 11971
Telephone '17-q
411
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- -- for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
•
DATE 6/2-//aZ
OWNER NAME: f1/ / &' 7' `'`�J�&'77� /Z z/ /
OWNER MAILING ADDRESS: 3,0• /L/Z%/`/ C/'d
v,/ //9 7
OWNER._PROPERTYADDRESS: -6-0/77e., - - -
OWNER TELEPHONE NUMBER: ,7 5— 4/(&45
TAX MAP NO. : Section 55a• /9 Block Lot
CROSS STREET:,
TYPE OF SYSTEM: Septic-Tank, = •-, New Existing
Cesspool New Existing
Residential - Non-Residential
DATE OF PREVIOUS PUMP-OUT:,
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.)
-------4Signature of Ap.lica t
RECEIVED, BY:
Town Clerk's Office
DATE: