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N �'1 P.O. Box 1179
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JUDITH T.TERRY 1-,;,,/�, 5 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. 661-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner RAKOWICZ, STANLEY M.
Mailing Address 1 BOX 142
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6178
Tax Map No. section 102. 00 block 1 lot 15 .000
Cross Street CASES LANE
Date Of Last Pump Out 0/00/00
1S.1
Issue Date,: 3/29/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c31FOGr =
Town of Southold .�� cQG', Application NW
Judith T. Terry, Town Clerk x,"� 7
Town Hall, 53095 Main Road Pz'>' `' r4 Residential
P. O. Box 1179 _ ,4. �� Non-Residential
Southold, New York 11971 O ® *-
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Telephone �.(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $10,
DATE 3A.7-,..2-/ere
OWNER NAME:5T/1-/(J4 / /i-1/C�DGtJ�GZ
OWNER MAILING ADDRESS: K i/
Cuichc o iU // 3S"
OWNER PROPERTY ADDRESS: f%2%z.i) ie0/9c/
CetiTc-A lie. -.( /(1.,
OWNER TELEPHONE NUMBER: 73 /- ‘/78
TAX MAP NO. : Section /0,2 Block / Lot /.0
CROSS STREET: 6cC� G4sc16T
TYPE OF SYSTEM: Septic Tank Or New Existing
Cesspool ✓ New Existing L/
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: ��E /rj67
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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Signa ur- of�
RECEIVED BY:
Town Clerk's Office
DATE:
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