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ELIZABETH A.NEVILLE ��� = �� ; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS °"• 0 Fax(516) 765-1823
MARRIAGE OFFICER �� ✓� ®�/ Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER ��
FREEDOM OF INFORMATION OFFICER ����
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3819-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner THOMAS WOWAK
Mailing Address 1 BOX 486
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 2805 MAIN ROAD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5273
Tax Map No. section 125.00 block 1 lot 2.800
Cross Street
Issue Date: 9/24/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFI(E OF THE TOWN CLERK 5�FHU(
'TOWN OF SOU• THOLD p�� C� Application No.
ELIZABETH A. NEVILLE,'I'OWN CLERK ', ;: r `. �� $10.00 - Residential
P.O. BOX 1179 ~• ; $25.00 - Non-Residential
,SOUTHOLD, NEW YORK 11971
0. =. . O!- ,11
Telephone _01 �� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION-PERMIT
SEPTIC TANK or CESSPOOL
7
Operation Permit No. MC
Fee $ /o .66 -
1 DATEc. .,__2„. �Zi, -
• OWNER NAME:• 'yr,-t.-, G'l/O fv /�- •
OWNER MAILING ADDRESS: j- ,d X_ �./
Z--e2---2,/}- 1.,--17.11 A/4/ )) 9Y1r----' -
OWNER PROPERTY ADDRESS: S�J,v' ,
OWNER TELEPHONE NUMBER: 2 y� �_
a I
TAX MAP NO. : Section /,02� Block / Lot Y
CROSS 'STREET: /14---v �Pe/
ti
TYPE OF SYSTEM: Septic Tank t New Existing ' /
Cesspool New Existingl/
Residential v Non-Residential
DATE OF PREVIOUS PUMP-OUT: / V '
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 clsest road.)
. 4._,K/.4.,1,,,.1
gnature of Applicant
I / 'RECEIVED BY: / 1�.d / _-
—Town -r 's O'fic-
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DATE: ..da' %'.
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