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JUDITH T. TERRY z O ` Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICE
R®� ®�.. ,t Fax (516) 765-1823
®1 4 �D 0� 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. 2096-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SLEZAK, FRANCES
Mailing Address 1 7405 ALVAHS LANE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 7405 ALVAHS LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5437
Tax Map No. section 101 .00 block 1 lot 16.002
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/19/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
" FFICE OF THE TOWN CLERKFD�•I��-
''town of Southold �� ; �CQG• Application No. c209
Judith T. Terry, Town Clerk `r" —
Town Hall, 53095 Main Road ': -' $10.00 - Residential
p. O. Box 1179 ` •` $25.00 - Non-Residential
Southold, New York 11971 O r o .,.��
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Telephone .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE Marc- y1 ��, 1 re/q3
OWNER NAME: gncf s cS,1e. k)
OWNER MAILING ADDRESS: 74135 )11,to s L4n-e
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OWNER PROPERTY ADDRESS: Lb - -5
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OWNER TELEPHONE NUMBER: 7,3 L1-5 9 3 -
TAX MAP NO. : Section /0 / Block / Lot i6 ,
CROSS STREET: No in-14 AQ &D
. TYPE OF SYSTEM: Septic `
Tank New Existing ✓
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ift,2 b / �,�� J C itutMI .
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 Ap ican
O
RECEIVED BY• _A �
Tow Cler 's Office
RECEI D
DATE:
APR 07 '1993
•
Southold Town Clerk
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