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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK CD) T • P.O. Box 1179
Southold,
REGISTRAR OF VITAL STATISTICS
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. 1624-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MISKA, JOHN JR.
Mailing Address 1 825 MARRATOOKA LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 825 MARRATOOKA LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9197
Tax Map No. section 115.00 block 4 lot 7.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/80
Issue Date: 2/20/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFIC, 'OF" THE TOWN CLERK SWFOU( '-
Town of Southold ® eo - Application No. J6 a, 4-7
Judith T. Terry, Town Clerk 1.
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Town Hall, 53095 Main Road --4��.?� -� I $10.00 - Residential
4,,,m_ � �yl
p. O. Box 1179 cr' k ,
� ,�._1 � $25.00 - Non-Residential
Southold, New York 11971 O ` ® ' O7J�
Telephone /iOj� ~`��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE c:;:2-,/,' /9/
. OWNER NAME: / Si, e
OWNER MAILING ADDRESS: A.2 .-
/�� ie./9 to 1,4 '
. 0: ;/J /6// . //,',3":2
OWNER PROPERTY ADDRESS: 9.12-7e/ /PS / `t .i
OWNER TELEPHONE NUMBER: ay,- 9/f7
TAX MAP NO. : Section //5 Block el/ Lot 7
CROSS STREET: /,./A7/ AM
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X-
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:_ , Zii 1 /5 5 / 'ry
2
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.)
t /,._,
gra re ot A ricant
RECEIVED BY: df.
Toew-rellerlOffice
DATE:
FEB 1J 151
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