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JUDITH T. TERRY �; aFl� } _ Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK ' . t;+ Southold, New York 11971
REGISTRAR OF VITAL STATISTICS efB
MARRIAGE OFFICER ���' Fax (516) 765-1823
`14,47 ®�$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. 1834-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner STEPNOSKI, ALEXANDER
Mailing Address 1 OLD NORTH ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 ' OLD NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-4312
Tax Map No. ' section 54.00 block 3 lot 24.003
Cross Street HORTON'S LANE
Date Of Last Pump Out 0/00/00
Issue Date: 1/22/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•• ••.
OFFICE OF THE TOWN CLERK •SUFFOC,+- =
Town of Southold ® E CQG'; Application No. / g..3 /
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road . $10.00 - Residential
P. O. Box 1179 5' ai ,' _
$25.00 - Non-Residential
Southold, New York 11971
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Telephone _ ,( �►'
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /1
OWNER NAME: ,11EY, ,vie-7? 57:67~St e
OWNER MAILING ADDRESS: Q1- 4. f 7 1e
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OWNER- PROPERTY ADDRESS: 04-ID 8d
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OWNER TELEPHONE NUMBER: 6 °- 43 /Q.
TAX MAP NO. : Section 5"'i( Block 3 Lot 4,"3
CROSS STREET: /6R.7;v !C 1...4,446" -
TYPE OF SYSTEM: Septic Tank- New Existing
Cesspool 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.)
zaG�
ignature of Applicant
RECEIVED BY: l/U
ow Clerk's Office
DATE: '
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