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OFFICE OF THE TOWN CLERK 1 ` -
Town of Southold �� CG
- Judith T. Terry, Town- Clerk � ' 'e
Town Hall, 53095 Main Road
P. O. Box 1179 to x ��
Southold, New York 11971 p ® !�
Telephone ,( 1/4
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 399 Residential x
Fee $ 10.00 Non-Residential
Septic Cesspool x
- NAME OF OWNER: Dorothy Mihalko
OWNER MAILING ADDRESS: Bayberry Road
Southold, New York 11971
OWNER PROPERTY ADDRESS: Bayberry Road
Southold,. New York
OWNER TELEPHONE NUMBER: 516-765-3535 or 3357 •
TAX MAP NO. : Section 76 Block 1 Lot 6
CROSS STREET: Bayview Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Residential X Non-Residential
•
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. Terry
Southold Town Clerk
DATE: August 14, 1987
(TOWN SEAL)
.. „ „_
OFFICE OF THE TOWN CLERK �S�FFD(/r�'`
Town of Southold ,'% ., CQG- , Application Nc ?
Judith T. Terry, Town Clerk �` `"
Town Hall, 53095 Main Road , w 04.-4,-4' ''� Residential
P. O. Box 1179 cn -• 3.,i3::4411 ,z' Non-Residential
Southold, New York 11971 - O % 4.7:"A
P.
Telephone "fel * �� .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL '
' Operation Permit No.c 9
Fee $ `Q
DATE
OWNER NAME: IP,-- ,'>v/ *=4;e- -Z,
OWNER MAILING ADDRESS:/ eddy iglu l` lei
CT/2Z >4-i(46 112. V. i /9' 7/ ,
OWNER PROPERTY ADDRESS: fly/e_eq/e j,9,�� 0815-A-
.
076,e,-, i(�-� / 1,1r,' //.9'7/
OWNER TELEPHONE NUMBER: S'/� 76.5- --arrg5-- 76-5 c3'7
TAX MAP NO. : Section ; �� Block Lot ��y
CROSS STREET: ,
kJ(ryU.cot. 41.
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ,z/ Non-Residential
- DATE OF PREVIOUS PUMP-OUT: �� -j,'6,,7h
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.)
s ji --- i
' Sig,'•ture of Applicant
RECEIVED BY:G � �
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Town erk's Of ice
DATE: ai.,,, ,., 1
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