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Town Hall, 53095 Main Road
v` P.O. Box 1179
_ o s� Vtol es- Southold, New York 11971
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JUDITH T.TERRY 1°`IFAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 1121-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SLAVONIK, FRANK AND NORMA
Mailing Address 1 P. O. BOX 143
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 BOISSEAU AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3204
Tax Map No. section 62.00 block 1 lot 19.000
Cross Street MAIN ROAD (ROUTE 25)
Date Of Last Pump Out 0/00/00
Issue Date: 5/24/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cOFfJ -
Town- of Southold - Application N3�. CQ '; Application No. % /2-/
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
cn t a } Residential
j�C
P. O. Box 1179 , • x ; Non-Residential
Southold, New York 119710 " �J
Telephone jt 0 ''
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
,for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ v
DATE M (A, i 1`i?�J
OWNER NAME: Iii ivify-/r aIZWIY$ 5.4 AVON /
OWNER MAILING ADDRESS: f? 0 , ry 30- x; /13
sou o• LO, , 4 ( ( 9 ? /
OWNER PROPERTY ADDRESS: '¢3 S S A u" f)'Ut'
S 0Z- .1)
OWNER TELEPHONE NUMBER: 766--- 3D- a
TAX MAP NO. : Section ( a— Block ( Lot IC?
CROSS STREET: Q v 5`'
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X. New Existing �\
A 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.)
• Signature of Applicant
RECEIVED BY:
Rietw Clerk's Office
DATE:
;11AY isd
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