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,•• Town Hall, 53095 Main Road
: � •' P.O. Box 1179
®� ,i�" Southold, New York 11971
JUDITH T.TERRY -% :i.�%�'�� 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. 1574-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIDOR, MARTIN
Mailing Address 1 BOX 841
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 2010 OREGON ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8086
Tax Map No. section 100.00 block 4 lot 4.000
Cross Street MILL LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/30/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
4
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OFFICE OF THE TOWN CLERK c3�FFO(,(r�'-
Town of Southold O CQ ' Application No. /,_S--7(
Judith T. Terry, Town Clerk % ,,..!;',;: ,i5-;:. �►
Town Hall, 53095 Main Road -sSt $10.00 - Residential ,./
P. O. Box 1179 (.1-3Y ';,!,';67,:;.9 ; $25.00 - Non-Residential
Southold, New York 11971 O -i. .`
Telephone 110 ' '44 f
1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 60_1'. aS / 97
OWNER NAME: R-%/iti ca'do
OWNER MAILING ADDRESS: L J ro'
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OWNER PROPERTY ADDRESS:- ---e5.2-7/7-0 E&O,t2 ,e.d _ --
M./9-7-77; O l/e-
OWNER TELEPHONE NUMBER: 2 ' — Me-6/PG 3 I
TAX MAP NO. : Section 7:0 p Block c7 Lot V
CROSS STREET: /r 1/ /J9-/U
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool // New Existing
Residential P1 Non-Residential
DATE OF PREVIOUS PUMP-OUT: eo qd
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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2( -o)?--(2`7't ed 1 , ` x-`7 01
5 a4 ' '
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Signature of Applicant
RECEIVED BY:
Tew,CLrk's Office
13-ATE: OCT 3 0 1B-,
Ion Met Southold