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JUDITH T. TERRY �� . Town Hall, 53095 Main Road
TOWN CLERK Z •
P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ® Tcrs Southold, New York 11971
MARRIAGE OFFICER �'%�, Fax (516) 765-1823
V VN. • 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. 1684-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner OSTROSKI, LEROY S.
Mailing Address 1 P. O. BOX 548
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 200 WILLOW POND LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3358
Tax Map No. section 70.00 block 8 lot 44.000
Cross Street CLEARVIEW
Date Of Last Pump Out 0/00/00
Issue Date: 5/07/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OF THE TOWN CLERK cvVFO(,(- -
Town of Southold �� +CQG', Application N4 /�
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Judith T. Terry, Town Clerk . . ' t
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Town Hail, 53095 Main Road :G $10.00 - Residential
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P. O. Box 1179 u' �' '. $25.00 - Non-Residential
Southold, New York 11971ma' -t J�
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Telephone =
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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 /_ 3o .- 9 /
OWNER NAME: ,� �?o c S (0S�'as,&c'
OWNER MAILING ADDRESS: Op / //ozd ,477G/ 6 . �2s}(.52c9
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OWNER PROPERTY ADDRESS: ,5 6
OWNER TELEPHONE NUMBER: 7S-2-2358
TAX MAP NO. : Section lib Block Lot
CROSS STREET: CItA)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing 1?(
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: j)'C /�� /99eY
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.)
rte' 44`
ig- ature of Ap.licant
RECEIVED BY:
Two, k's Office
DATE: APR 3 0 1qc
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