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JUDITH T. TERRY ,O . Town Hall, 53095 Main Road
TOWN CLERK P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS tr2 J Southold; New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER ` ® •
�r la® 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. 3115-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner PET KAS, THEODORE
Mailing Address 1 257 STEWART AVENUE
Mailing Address 2
City St Zip BETHPAGE NY 11714-0000
Property Address 1 COUNTY ROUTE 48
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-731-20111
Tax Map No. section 135.00 block 1 lot 27.000
Cross Street SOUNDVIEW AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKSVFFO(,(r =
Town of Southold �� �C ' Application No. '31 I
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Judith T. Terry, Town Clerk �`� sr,
Town Hall, 53095 Main Road 1.)
$10.00 - Residential
P. O. Box 1179
1 ` $25.00 - Non-Residential
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Southold, New York 11971 • *$
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Telephone 1
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for RECEIVED
OPERATION PERMIT 1�3
SEPTIC TANK or CESSPOOL
S®utS�Pa,®Id�3 I®�4yp� Clerk
Operation Permit No.
Fee $ •
y DATE g gjs
OWNER NAME: .-1- (0.s2, o 1?T 1
OWNER MAILING ADDRESS:
OWNER PROPERTY ADDR_ESS: 7 lI� , A/0rn.--t/e p-o`Q-9
OWNER TELEPHONE NUMBER: c'-/,‘
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TAX MAP NO. : Section / `'3 Block f Lot 2,7
CROSS STREET: JoIJ,jv ) Lf c'
• 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.)
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Sign.' ure of A•plicant
RECEIVED BY: -
Town CI rk's Office
DATE: - 62^ `�j', p
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