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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T • P.O. Box 1179
REGISTRAR OF VITAL STATISTICSurs .' Southold, New York 11971
MARRIAGE OFFICER '"- ® ®� •1 Fax (516) 765-1823
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b Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2033-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SKWARA, CHESTER
Mailing Address 1 3720 WELLS ROAD
Mailing Address 2
City St Zip PECONIC NY 11958-0000
Property Address 1 3720 WELLS ROAD
Property Address 2
City St Zip PECONIC NY 11958-0000
Owner Telephone No. 516-765-2741
Tax Map No. section 86.00 block 1 lot 14.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/88
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK oSOFO1/r..„-
Town of Southold 0�� CQG Application No. 0-0 �
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Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential.
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P. O. Box 1179 '�*i�� $25.00 - Non-Residential
Southold, New York 11971 O ®_4w-f-'',__�`
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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 $
DATE
OWNER NAME: C .sok/ £7<'J/VARA
OWNER MAILING ADDRESS: , 0 ,/ /),8- S ,a,
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OWNER PROPERTY-ADDRESS:
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OWNER TELEPHONE NUMBER: 0/6 — 76 . — 71‘/
TAX MAP N6-.-: Section D Block / Lot / 5( _
- CROSS STREET: P±E c-
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TYPE OF SYSTEM: -Septic -Tank- --,_ ---- — .;. lew Existing
Cesspool New Existing `_.----
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /4
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
l of distance, approximately, to building and closest road.)
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Signature of Applicant
RECEIVED BY: _ , CA-1,..4"0/41--,-- 1 -
' --- ' Town Cle'rk's Office
DATE: -. .j-�/.3( - -
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