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OFFICE OF THE TOWN CLERK ' r.gfetir
Town of Southold
Judith T. Terry, Town Clerk r ��
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Town Hall, 53095 Main Road ,h 4a^, •
P. O. Box 1179 c� `� iN
Southold, New York 11971 ,\ � 516
Telephone 701 * ASO
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation_ Permit No. 559 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Olqa Wydro
OWNER MAILING ADDRESS: P.O. Box 795
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: 850 Marratooka Lane
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-9109
TAX MAP NO. : Section 115 Block 3 Lot 16
CROSS STREET: Main Road and New Suffolk Avenue
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown •
•
Judith T. Try
Southold Town Clerk
DATE: January 5.• 1988
•
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold 0�� CQG';. Application No.
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road o f As'?k : Residential
P. 0. Box 1179 .'*;; i , Non-Residential
Southold, New York 11971 4 ® `A" t
Telephone •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
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OPERAT ION PERMIT
SEPTIC TANK or CESSPOOL
Operation. Permit No.
Fee $
DATE
OWNER NAME: 0 A - \'VyzD
OWNER MAILING ADDRESS: P ®. 79.5-
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OWNER PROPERTY ADDRESS: 94-R a 9 I)c /cz3- ) si N
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OWNER TELEPHONE NUMBER: gam'- 9/ 2 ci
TAX MAP NO. : Section �� Block Lot l&
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CROSS STREET: Il 13:1)V R pl N (� ,,� u I'-re L-W rr V •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential t,../ Non-Residential
- DATE OF PREVIOUS PUMP-OUT: ? --//- f- 7
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:
Town Clerk's Office
MEW 1
DATE:
JAN 05S G
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