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tgt � ��` Town Hall, 53095 Main Road
�®� ��'•�� P.O. Box 1179
'- ,.vo " Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1490-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PIETREWICZ, ALBIN
Mailing Address 1 500000X LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address t 500i1COX LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6305
Tax Map No. section 96.00 block 2 lot 10.000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 6/26/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
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OFFICE OF THE TOWN CLERK c•OFO(,- !/
Town of Southold �. .• ,:_ •-13:-I Application No.
Judith T. Terry, Town Clerk ` '
Town Hall, 53095 Main Roads i .G 1 $10.00 - Residential
P. 0. Box 1179 Z{5; 7 ; $25.00 - Non-Residential
Southold, New York 11971 OO Ne."Telephone j N e
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
i1
Operation Permit No.
Fee $
DATE C/
• OWNER NAME: 701_e Ai I i ,C l 1Z •
OWNER MAILING ADDRESS: 0 0 I o Je) S 19-
tc J a6 cac.; A . / J (7,3 5 -
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: ,3 3 % - t 6) 5 •
TAX MAP NO. : Section Block c Lot Id
CROSS STREET: 1J ! Lf>3
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.)
Signat - of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
Ce I /,