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JUDITH T. TERRY 1. Town Hall, 53095 Main Road
TOWN CLERK 1:=1
T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS U1 Southold, New York 11971 •
‘10°
� Fax (516) 765-1823
MARRIAGE OFFICER o�
+ .4 I•' 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. 2085-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner WISNIEWSKI, FRANCES
Mailing Address 1 P. O. BOX 172 -
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1540 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6197
Tax Map No. section 103.00 block 11 lot 12.000
Cross Street FLEET NECK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK O�OFp(A'
Town of Southold CQG' Application No. c)6�5i
Judith T. Terry, Town Clerk . y
Town Hall, 53095 Main Road -� $10.00 - Residential
P. O. Box 1179 v' ► .` $25.00 - Non-Residential
Southold, New York 11971 00 ,
Telephone
(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: FR 19 c e 5 LJ/StL1/E'tJS fri
OWNER MAILING ADDRESS: P.O. &d,r7—
C, v ''cJto v e, /t1. -. 1/93.E
OWNER PROPERTY ADDRESS: /f9 s P9d E
OWNER TELEPHONE NUMBER: 5--/4 - 7.3 s/— /97
TAX MAP NO. : Section MDLS Block ( Lot ia_,
4'73 ,f1/- /°3 'i- 12
CROSS STREET:
TYPE OF SYSTEM: Septic_ Tank ✓ New Existing
Cesspool l/ New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: ,06/3`-f- /.(py,jc)
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
pp
RECEIVED BY:
Town Clerk's Office
DATE:
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