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JUDITH T.TERRY �.� Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS t, *' Southold, New York 11971
MARRIAGE OFFICER ��� Fax (516) 765 1823
® / 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. 1686-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SUJESKI, WALTER
Mailing Address 1 290 PINE STREET
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 290 PINE STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9464
Tax Map No. section ' 41 .00 block 1 lot 29.000
Cross Street WESTPHALIA ROAD
Date Of Last Pump Out 0/00/81
Issue Date: 5/07/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •..
OFFICE OF THE TOWN CLERK �c3�FFUI L�'-
Town of Southold C'� Application No. /t
Off'Y G •
Judith T. Terry, Town Clerk
:. �f 7 $10.00 - Residential
Town Hall, 53095 Main Road �^i �
, p. O. Box 1179 f-r' = '"^ i • $25.00 - Non-Residenti
Southold, New York 11971
Telephone 701 •
, Y►�� '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 14. 24 -
Fee $ /46-1:11
DATE 361Q/
OWNER NAME: ec)Cajtjjtj
OWNER MAILING ADDRESS: Alp
1-?9ortA,-tetc,0 n 41/
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: y g" / T b
TAX MAP NO. : Section J 41 / Block / Lot 7
CROSS STREET:'
TYPE OF SYSTEM: Septic Tank New Existing IV
Cesspool ✓/ New Existing ✓
Residential 1✓ Non-Residential •
DATE OF PREVIOUS PUMP-OUT: / 9,/
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.)
P
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Signature o pp scant
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RECEIVED BY: li���._: %1/:�� ,
.w r lerk's Office
DATE: �S' `%
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