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Er wTown Hall, 53095 Main Road
P.O. Box 1179
t. ®'��® ilt `.°0'Is•' Southold, New York 11971
JUDITH T.TERRY =—.- ,/oir'' FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1529-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ORLOWSKI, ALBERT
Mailing Address 1 P. O. BOX 1233
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6656
Tax Map No. section 102.00 block 5 lot 20.000
Cross Street NORTH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 9/25/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �c�AFFair
Town of Southold C'QG� Application No. /5„:47
Judith T. Terry, Town Clerk $10.00 - Residential
Town Hall, 53095 Main Road '-E
p. O. Box 1179 u' ' , " - .' h� $25.00 - Non-Residential
Southold, New York 11971 O , 0 �f
Telephone j ' �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /7 a / 9.9c
'OWNER NAME: ALBERT ORLOWSKI • •
MAIN STREET-BOX-1432 12 33
OWNER MAILING ADDRESS: CUTCHOGUE. N.Y. 11935
OWNER PROPERTY ADDRESS: frkg-
OWNER TELEPHONE NUMBER: 7 3 C-G
TAX MAP NO. : Section (�� Block Lot igen .
CROSS STREET:
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.)
Signature of Applicant
RECEIVED BY:
own Clerk's Office
-DATE: 76" l
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