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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER
� i�' 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. 1843-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool �X
New Existing X
Name Of Owner TERESKO, WALTER
Mailing Address 1 P. O. BOX 963
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1285 NEW SUFFOLK ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5934
Tax Map No. section 109.00 block 7 lot 6.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/80
Issue Date: 2/12/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
- "" TOWN CLERK ' �FFO(,(-
%r°;'Y';irw;,uthold 0 � 4 . , Application No. /?Y3 •
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,-, n f. Terry, Town Clerk
awn Hall, 53095 Main Road = -< $10.00 - Residential
P. O. Box 1179 '. - z ; t ; $25.00 - Non-Residential
Southold, New York 11971 O ® Ot' ��`�
Telephone �,( ' '�
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(516) 765-1801 •
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
1
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee
DATE g / 'ifq
2-
OWNERNAME:_u� �// j
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OWNER MAILING ADDRESS: f . x4,t 9‘3
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OWNER PROPERTY-."ADDRESS: / rc
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OWNER TELEPHONE NUMBER: 73
TAX MAP NO. : Section /4 ?..- -7=6, Block 7 Lot
CROSS STREET: —(..) ti
TYPE OF' SYSTEM: Septic Tank New Existing
Cesspool V New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /67 t')
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:'-•s
Town Clerk's Office
DATE:
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