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JUDITH T. TERRY jy Town Hall, 53095 Main Road
n P.O. Box 1179
TOWN CLERK ``� "�
REGISTRAR OF VITAL STATISTICS ; r Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
V i° Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1813-R' Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SLEDJESKI, HELEN
Mailing Address 1 BOX 1183
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 370 VILLAGE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4997
Tax Map No. section 114.00 block 6 lot 20.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/26/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III
OFFICE OF THE TOWN CLERK c3� FFO(,r��=
Town of Southold ✓ � uCQG'� Application No.
Judith T. Terry, Town Clerk :tom ,
Town Hall, 53095 Main Road - $10.00 - Residential �—
P. 0. Box 1179 5' =2.? Fl ' ► �`'
$25.00 - Non-Residential
Southold, New York 11971 4 ,Telephone 5 ?j' 4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
1 .
DATE ///,2.'/ �7
OWNER NAME: e(e n 31,0 -,,,s/r/
OWNER MAILING ADDRES �� ��� _' h c J7 `e be-(7..,/,( P3
i1 ri- /`T orc , � //OWNER PROPERTY ADDRESS: 3 7 b 1) i '/% -e Q,
Aics T/ grid /1•1 ft ,'_,Tai—
/
OWNER TELEPHONE NUMBER: c). y'f'— 4/ 777
TAX MAP NO. : Section // 4/ Block 6 Lot 00
CROSS STREET: (--7),-76-..e77-
'TYPE OF SYSTEM: Septic Tank' ' New Existing
"' Cesspool, t" New Existing
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.)
61 �
Signature of Appl' ant
RECEIVED BY: X
Town lerk's Office
DATE: RECEIVED '
Town Clerk Southold