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JUDITH T. TERRY ; Z Town Hall, 53095 Main Road
TOWN CLERK ® ►Z P.O. Box 1179
REGISTRAR OF VITAL STATISTICSf$ Southold, New York 11971
MARRIAGE OFFICER �® o�.. Fax (516) 765-1823
- �1� �� Fax
(516) 765-1801
1111 iOii
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3016-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PUPECKI, JENNIE
Mailing Address 1 P. O. BOX 366 -
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 PECONIC LANE
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-3584
Tax Map No. section 74.00 block 3 lot 13.000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/86
Issue Date: 5/07/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c0FOUr
Town of Southold � :-yam �QG Application No. 5®/)
Judith T. Terry, Town Clerkt. :'` v�
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cn ;. : ►
$25.00 - Non-Residential
Southold, New York 11971 • O410~`r �O�0*�`
Telephone -_ 11( l •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 36 /6
Fee $
DATE ‘:_iy OP
OWNER NAME: t,-„,1( )
OWNER MAILING ADDRESS: tXn b
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OWNER PROPERTY ADDRESS: e 1 )7
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OWNER TELEPHONE NUMBER: z---)
TAX MAP NO. : Section 7 ( Block 5 Lot / 3
4�TYPCROSS STREET: fl 1-e 140--
TYPE
E 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.)
c,,,t17fryLAn, 07-144'e-ai
Signature of Ap icant
RECEIVED BY:
Town Clerk's Office
DATE: — 6 ��
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