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JUDITH T.TERRY tisA# Town Hall, 53095 Main Road
TOWN CLERK ; y $41
P.O. Box 1179
w $ Southold,New York 11971
REGISTRAR OF VITAL STATISTICS V ®
MARRIAGE OFFICER `� 44/ 'e1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER ®.( .�i 0/ Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER "--
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3666-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MILOWSKI, FRANK
Mailing Address 1 P. O. BOX 456
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 700 JOHN ROAD
Property Address 2 •
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4795
Tax Map No. section 122.00 block 3 lot 22.000
Cross Street MAIN ROAD
Issue Date: 7/23/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.;
OFFICE OF THE TOWN CLERK ��FO �'
Town of Southold ���: �Ol Application No.dC‘-6
Judith T. Terry, Town Clerk `l $10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 ) $25.00 - Non-Residential
Southold, New York 11971 OII ��i'$''
Telephone .� lit
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 2 `I 77
OWNER NAME: /.Z
OWNER MAILING ADDRESS: 7,0 \�/AZ • /l .'' O/C'
OWNER PROPERTY ADDRESS: / '/-�
OWNER TELEPHONE NUMBER: 77
TAX MAP NO. : Section /a d. Block 3 Lot �01-1
CROSS STREET: v ' / Cw� �
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool New Existing
Residential Non-Residential
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.)
,F7*401111
Si . re of Applicant
RECEIVED BY: Toper-
wn lerk's Office
DATE: