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Town Hall, 53095 Main Road
d® P w' P.O. Box 1179
_ f Southold, New York 11971
JUDITH T.TERRY �`�I 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. 989-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RUTKOWSKI, ANTHONY
Mailing Address 1 P. O. BOX 299
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 6125 PECONIC BAY BLVD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4044
Tax Map No. section 126.00 block 10 lot 24.000
Cross Street BIRCH ROAD
Date Of Last Pump Out 5/00/82
Issue Date: 1/10/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK COF (,' ''•
Town of Southold �Q C ApP lication No.
Judith T. Terry, Town Clerk �� a,;V.„-i`' o4
Town Hall, 53095 Main Road a Residential
P. O. Box 1179 v' ICK , 9 i ; Non-Residential
Southold, New York 11971 O 'er 4 P ' �$
Telephone OI #1•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
EPTIC TANK or CESSPOOL
Operation Permitoo
No.
Fee $
DATE ( l
OWNER NAME: A +k0 � S(cz`
OWNER MAILING ADDRESS: , U , y �
I'/Y\a._(f i N . ,
OWNER PROPERTY ADDRESS: re_La V'L 1�cLiecoa
OWNER TELEPHONE NUMBER: (..1 - 4-0 44-
TAX
-TAX MAP NO. : Section i-(o Block ( ® Lot d24-
CROSS STREET: 3 r-cC
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.)
LLA-tia,.._A_)i (129
Signature Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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5 A ` SUFF.CO.TAX MAP-DIST.1000 SECT.126 BLK.IO LOT 2.4
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' SURVEY FOR
•$o�- ANTHONY RUTKOWSKI a KATHERINE RUTKOWSKI
�e
oti �� AT LAUREL - •' . i)' DATE : FEB. 27, 1981
TOWN OF SOUTHOLD yi' SCALE: 1"=40'
�� SUFFOLK COUNTY, NEW YORK l' NO. : 81-52
• - *UNAUTHORIZED ALTERATION OR ADDITION TO THIS GUARANTEED 40!
SURVEY IS A•VIOLATION OF SECTION 7209 OF TE
NEW YORK STATE EDUCATION LAW THE TITLE GUARANTEE COMPANY
*COPIES OF CHIS SURVEY NOT BEARING THE LAND
SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL
,, r NOT BE CONSIDEREDDTO BE A VALID TRUE COPY:'
> ..4 r' THE PERSON FOR WHOM THE ESURVEY IREON AS PREPARED,
LL RUN ONLY TO S�PSE OF NES'
AND ON HIS BEHALF TO THE TITLE COMPANY,GO;VERN- p
•
MENTAL AGENCY AND LENDING INSTITUTION LISTED �p,r<tb '. y p�
HEREON,AND TO THE ASSIGNEES OF THE LENDING p r
INSTITUTION. GUARANTEES ARE NOT TRANSFERABLE .IG.
TO ADDITIONAL INSTITUTIONS OR SUBSECUENT, * 4E4
.
OWNERS �c
• *DISTANCES SHOWN HEREON FROM PROPERTY LINES 1 �~ih, 1 ".t
TO EXISTING STRUCTURES ARE FOR A SPECIFIC k j"'"
PURPOSE AND ARE NOT TO BE USED TO ESTABLISH
PROPERTY LINES OR FOR THE ERECTION OF FENCES. ii
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