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Town Hall, 53095 Main Road
P.O. Box 1179
`�� Southold, New York 11971
JUDITH T.TERRY
®� ����� FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
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. 959-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VEROSTEK, CONRAD
Mailing Address 1 50 GROVE ROAD
Mailing Address 2 MILL COLONY
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 MILL CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3780
Tax Map No. section 135.00 block 3 lot 30.001
Cross Street GROVE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 12/19/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
••
OFFICE OF THE TOWN CLERK ••COMA'
Town of Southold
0� OG Application No. 9S
Judith T. Terry, Town Clerk . y
Town Hall, 53095 Main Road ` ' Residential
P. 0. Box 1179 - ` i ; Non-Residential
Southold, New York 11971 O `` �1`,
Telephone- �j Y� ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: (IDA12/,‘ h7
OWNER MAILING ADDRESS: Si ��p U 2]{�\RA,
N-) / 112 /
OWNER PROPERTY ADDRESS: /L///.., _ (' f)/2_1
5d ii %htoLO ,� >I' /1 9 7
OWNER TELEPHONE NUMBER: ,g7/6, — ?‘j--
TAX
‘j=TAX MAP NO. : Section / 3 Block j Lot -60. /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank �ew 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: ,COX.1 , t
jown Clerk's Office
DATE: � /60/0
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