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Town Hall, 53095 Main Road
��Y P.O. Box 1179
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Southold, New York 11971
FAX(516)765-1823
JUDITH T.TERRY
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. 1209-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SKUBLISKAS, BENJAMIN R.
Mailing Address 1 SKUBLISKAS, JOAN N.
Mailing Address 2 3200 DEEP HOLE DRIVE
City St Zip MATTITUCK NY 11952-0000
Property Address 1 3200 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000 •
Owner Telephone No. 516-298-8107
Tax Map No. section 115.00 block 17 lot 13.000
Cross Street THERESA DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 8/08/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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'(' FICE OF THE TOWN CLERK is
Town of Southold (10 Application No. 020
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ;��' '` 'zF�{ .. $10.00 - Residential
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P. O. Box 1179 �' ' t `^ t ' i $25.00 - Non-Residential
Southold, New York 11971 Oit; 0 ��`
Telephone `
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE `�1
'OWNER NAME: 80644 T11ln i\ ` JQF}-N / s 5koiei k.13-4c4s
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OWNER MAILING ADDRESS: Jc CO /74 Lv ®/e/I/z—
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: (;-2e )
TAX MAP NO. : Section NS- Block / 7 Lot /3
CROSS STREET: •71 fS5-- TR/a
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing a�
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
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�9�ii�vv/ JQ�
Signature of Applicant
RECEIVED BY:
Ierk's Office
DATE: AUG 08 19tm
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