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JUDITH T. TERRY Town Hall, 53095 Main Road
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TOWN CLERK t P.O.P.O. Box 1179
REGISTRAR OF VITAL STATISTICS _U1 �` - Southold, New York 11971
�� Fax (516) 765-1823
MARRIAGE OFFICER ® ®�,yol •
+ %ND �� 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. 2079-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOISA, EUGENE
Mailing Address 1 33195 MAIN ROAD -
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 33195 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-2760
Tax Map No. section 19.00 block 1 lot 13.000
Cross Street NARROW RIVER ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/18/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cOFI(A'���
Town of Southold Application No. a2 7/
Judith T. Terry, Town Clerk � i `� A
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 u' ` r : $25.00 - Non-Residential
Southold, New York 11971 OOx !- ��
Telephone :17_0 $‘6‘:
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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 ti/j1r If- `7,93
OWNER NAME: F�
OWNER MAILING ADDRESS: 33 ifs— "IAA,/ A)' 0-A/,i (7 lil y
1/,59
OWNER PROPERTY ADDRESS: 331gs JrJA-rir/ Ad) 0,LFiv�
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OWNER TELEPHONE NUMBER: 3,3 - g?fie
TAX MAP NO. : Section ) ! Block j Lot
CROSS STREET: ,) Dater
TYPE OF SYSTEM: Septic Tank New Existing e
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /'E'/3, 1,73
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: