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,4.,.. z Town Hall, 53095 Main Road
�� P.O. Box 1179
`___ ® ��_•••' Southold, New York 11971
JUDITH T.TERRY TELEPHONE
TOWN CLERK (516)765-1801
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. 708-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner PETROWSKI , PETER R.
Mailing Address 1 235 EAST LEGION AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 235 EAST LEGION AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9175
Tax Map No. section 122. 00 block 3 lot 14. 000
Cross Street BAY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ^.,�VFFU(�� �J
Town of Southold /Application No. 0
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road : Residential
P. 0. Box 1179 cn I& * : Non-Residential
Southold, New York 11971
Telephone : 1 • ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 7 0 F
Fee $ f®®-
DATE Li - /1
OWNER NAME: Riff/ /f , -/,P i jZ'
OWNER MAILING ADDRESS: a 3 S- 15 , 1-F6/041/
Aff i T /71-1 CK hY Y //93-62
OWNER PROPERTY ADDRESS: i
OWNER TELEPHONE NUMBER: t 29P - 7
,
TAX MAP NO. : Section (>
2 2 Block 3 Lot /
CROSS STREET: /5>9k' ,9/"t
TYPE OF SYSTEM: Septic Tank " New Existing
Cesspool )( New, Existing �9
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: U Ng//O'Gl/4/
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.)
i� ? /,\
F /• .
- Signature of Applicant
RECEIVED BY:
?1:12 wn Clerk's Office •
DATE: MAY 191998 •
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