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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS %trl
Southold, New York 11971
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MARRIAGE OFFICER Fax (516) 765-1823
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* NW,/ 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. 3099-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MICHALECKO, PAUL
Mailing Address 1 BOX 133
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 SOUND AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8476
Tax Map No. section 141 .00 block 3 lot 3.000
Cross Street FACTORY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •
Town of Southold /C��FF�(xl'•
� ;,;•:� OApplication No. �9P
Judith T. Terry, Town "Clerk' ''s �" y
Town Hall, 53095 Main Road
1 $10.00 - Residential
P. O. Box 1179 cryzy:>i ,".4'Y' $25.00 - Non-Residential
Southold, New York 11971 p ®
Telephone P�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.'O 9'9
Fee $
DATE /S/1-3
OWNER NAME: ;:?2,,,,, e-� • •
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OWNER MAILING ADDRESS: �i'1 � -� J 3„3
OWNER PROPERTY ADDRESS:, _ � / f
OWNER TELEPHONE NUMBER: �LC��" ?''7
TAX MAP NO. : Section / 41/ Block j Lot
CROSS .71-Y
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.)
i nature of Applicant
licant
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RECEIVED BY: Ati
Town Clerk's Office
DATE:
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