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JUDITH T.TERRY � � '�1 Town Hall, 53095 Main Road
TOWN CLERK 1=3 P.O. Box 1179
�, �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
V 4 � Fax(516) 765-1823
MARRIAGE OFFICER \44RECORDS ® ®�l��� Telephone(516) 765-1800
FREEDOM OF INFORMATIONNOFFICER NAGEMENT OFFICERd ����
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3634-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SAJNACKI, STANLEY
Mailing Address 1 P. O. BOX 440
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4255 DEPOT LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5305
Tax Map No. section 96.00 block 5 lot 7.000
. Cross Street EVERGREEN
Issue Date: 5/22/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK S�FFOL,r :'
Town of Southold , � CQ� Application No._
__Or
Judith T. Terry, Town Clerk .
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 $25.00 - Non-Residential
Southold, New York 11971 `
Telephone _ j •'�
(516) 765-1801. OF
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for '
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /•u.+)
DATE 5' 1
OWNER NAME: r
OWNER MAILING ADDRESS: "0• Zax 1C
OWNER PROPERTY ADDRESS: t1 $ 'S ad ! -
OWNER TELEPHONE NUMBER: Sf‘ � S 3 -7 S
� T
7
TAX MAP NO. : Section 91‘‘, Bleck Lot
CROSS STREET: EV�,2_.62CrF'_,4--)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool (I 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.),
Sig . 'ure of pplic nt
RECEIVED BY: AL
Town Clerk' Office
DATE: b/ 'ot C.)/Q>
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