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Town Hall, 53095 Main Road
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D. i`' P.O. Box 1179
_A ED O /° Southold, New York 11971
JUDITH T.TERRY
� � FAX(516)765-1823
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. 1063-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STARS'AK, STELLA
Mailing Address 1 P. O. BOX 475
Mailing Address 2 SCHOOLHOUSE ROAD
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 725 SCHOOLHOUSE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6606
Tax Map No. section 102.00 block 1 lot 25.000
Cross Street DEPOT LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/30/89 - Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK cl1FFite '-
Town of Southold C� Application No. /063
Judith T. Terry, Town Clerk . 1.7„,k: t .
Town Hall, 53095 Main Road ".,1 �L Residential
P. O. Box 1179 cr3 '. i ;' Non-Residential
Southold, New York 11971 O °® ''' '•
Telephone e; k\s: o
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE �f ,,F4
/. As,
OWNER NAME: lr�.���
_ f
,40/OWNER MAILING ADDRESS, , , TL / /
OWNER PROPERTY ADDRESS: /SII L�_rl��r%/ar-l'
A(•
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section /(..),2, Block l Lot
CROSS STREET: A
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool I New Existing
Residential t Non-Residential
DATE OF PREVIOUS PUMP-OUT: f/f,P
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.)
Signatu e of Applicant
RECEIVED BY: (Axa a C'4->1-
3 Jerk's ORE
DATE: MAR e, 1 u 11164
NriiR-fl-r 0ye s Pv 01 //(/- ill W.,
�s i. M S 474� �~
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