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JUDITH T. TERRY Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK FYI
REGISTRAR OF VITAL STATISTICSS .�` Southold, New York 11971
MARRIAGE OFFICER �® 'i�. Fax (516) 765-1823
q0- Telephone (516) 765-1801
ate, i407
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1860-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RUSKOWSKI, DOROTHY
Mailing Address 1 500 SMITH DRIVE SOUTH
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 500 SMITH DRIVE SOUTH
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3065
Tax Map No. section 76.00 block 3 lot 26.001
Cross Street BAYV I EW ROAD
Date Of Last Pump Out 0/00/81
Issue Date: 3/27/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
i) . ice.
OFFICE OF THE TOWN CLERK .c3IFOUr '-
Town of Southold �% - CQG- , Application No16 6 c)
O ,= ,ti__
Judith T. Terry, .Town Clerk : A , '� $10.00 - Residential
' Town Hall, 53095 Main Road }
P. O. Box 1179 . cr3 17 ' `' $25.00 - Non-Residential
Southold, New York 11971 - 4 V-,,_,‘
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Telephone o.( �es ' ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
.' APPLICATION
for .
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ • . -- - - . - - - -
DATE kg- v2`,- ?c-.1-
OWNER NAME: 16 Pc 1-1-(1/4/ U c/Ca toSIC
OWNER MAILING ADDRESS: X6 c Sni ' +-i. 1)e. So-c.z..(-
,So LLL1afel, IUy / NW
OWNER PROPERTY ADDRESS: o'v /h i4 UP. &aidi
a
ecaA /c1, I )L( ) iqi /
OWNER TELEPHONE NUMBER: LT/4fl f Jo 6 J l
j TAX MAP NO. : Section /(p Block 3 Lot c>7 6 - /
CROSS STREET: t 4 Li (wc-,4), AD
TYPE_OF. SYSTEM: Septic Tank . New Existing
Cesspool New Existing '
Residential . 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: - E-/6 `fv
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.)
\P" .y4.,-2_,Affer).tr of Applicant
, i
RECEIVED B RECEIVED
Town Clerk's Office
MAR 2 7t 1992
DATE: -
Southold Town Clerk '
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