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-V - K Town Hall, 53095 Main Road
® '`"' ,� $ P.O. Box 1179
__ '}r`rsii �o SIS, Southold, New York 11971
JUDITH T.TERRY '''.......woo-4"` re' FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 991-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TROJANOWSKI, RICHARD
Mailing Address 1 P. O. BOX 967
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 BREAKWATER ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8992
Tax Map No. section 113.00 block 3 lot 5.000
Cross Street WEST MILL ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/17/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OF EICE OF THE TOWN CLERK
Town of Southold Application No.
Judith T. Terry, Town Clerk �� w •
~ �
Town Hall, 53095 Main Road � ��� " V'S :G 7 Residential
p.
P. O. Box 1179 v' j,fk hi ` Non-Residential
Southold, New York 11971 �`0 �0\,••
Telephone - .( 4 Y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0, 00
DATE3o
OWNER NAME: /c iJ ' ,G -145.:?) , co < / r 7
e
OWNER MAILING ADDRESS: P°7±.9/ , [jo�,.� t ed.
OWNER PROPERTY ADDRESS:
//,/1'4- 7 IC C ,(7- /
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OWNER TELEPHONE NUMBER: ��fff?,,i
TAX MAP NO. : Section /j { Block 3 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank ✓ New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: Ofif=
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 A ph ant
RECEIVED BY: ,./ p, '
,Town Clerk's Office
DATE: JAN y 7 19,9q
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