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tai Town Hall, 53095 Main Road
r P.O. Box 1179
sz 4 Southold, New York 11971
JUDITH T.TERRY -Ls-- X101' FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1327-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SWIATOCHA, ZIGNOR G.
Mailing Address 1 BOX 346
Mailing Address 2 655 LESLIE ROAD
City St Zip CUTCHOGUE NY 11958-0000
Property Address 1 655 LESLIE ROAD
Property Address 2
City St Zip CUTHOGUE NY 11958-0000
Owner Telephone No. 516-734-6835
Tax Map No. section 97 block 4 lot 18
Cross Street SKUNK LANE
Date Of Last Pump Out 0/19/86
Issue Date: 11/30/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'c��FFD(,��
Town of Southold CQ Application No. J -1
Judith T. Terry, Town Clerk . ' ,
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Town Hall, 53095 Main Road $10.00 - Residential
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P. O. Box 1179 � � �'4 $25.00 - Non-Residential
Southold, New York 11971 �wI® O �J�
Telephone '�1®j
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE II -4i
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OWNER NAME: //` �/ � ' a--4Cdr
OWNER MAILING ADRESS: kie3:5), to- Rd — Boy 3g
OWNER PROPERTY ADDRESS :
OWNER TELEPHONE NUMBER: 5/4-- 4L_- 4225--
TAX
MAP NO. : Section
0
TYPE OF SYSTEM: Septic Tank[ New Existing
/
Cesspool v New Existing 'r
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: f iVe
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.)
4"
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' Sig- ature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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Ronkonkoma, N.Y. 516-588-4844
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A member of the Pilkington Group
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