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CP Fin`' Town Hall, 53095 Main Road
1+Q", VIII P.O. Box 1179
- -�®1iiii `A%00 Southold,New York 11971
JUDITH T.TERRY "williieI FAX 765-1823
TELEPHONE)16)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. 1537-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner POLIWODA, NATALIE K.
Mailing Address 1 55660 NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 55660 NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2156
Tax Map No. section 44.00 block 3 lot 2.000
Cross Street ALBERTSON'S LANE
Date Of Last Pump Out 0/00/86
Issue Date: 10/02/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•OFFICE V THE TOWN CLERK 1C��FF�( +'
_
Town of Southold Application No. x"37
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -T : $10.00 - Residential
P. O. Box 1179 to 4011 $25.00 - Non-Residential
Southold, New York 11971 "teO ®
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: 6G) /• r ) CU •
OWNER MAILING ADDRESS: ,c/a
72_70›, moi, , I /7 Y,'
OWNER PROPERTY ADDRESS: � (� C2
//9 >/
OWNER TELEPHONE NUMBER: ,37/
TAX MAP NO. : Section Block Lot
CROSS STREET: O ,&4 0 vQec—.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New X\ Existing
Residential u Non-Residential
DATE OF PREVIOUS PUMP-OUT: r / Yd 7
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.)
d
Signatur: of Applicant
RECEIVED BY:
- oTown Clcr� Jfce
DATE: oar 02 v
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