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OFFICE OF THE TOWN CLERK Nc0F01,(r`�
Town of Southold ,6 Off. �f. � G
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971 it4C1
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Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 38 Residential XX
Non-Residential
Fee $ 10.00
Septic Cesspool Xx
NAME OF OWNER: Chester Yousik
OWNER MAILING ADDRESS: 595 Pequash Avenue
Cutchogue, New York 11935
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OWNER PROPERTY ADDRESS:- 595 Pequash Avenue
Cutchogue, New York
OWNER TELEPHONE NUMBER: 516-734-5465
TAX MAP NO. : Section 103 Block 7 Lot 27. 1
CROSS STREET: First Street
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool XX New Existing XX
Residential XX Non-Residential
DATE OF PREVIOUS PUMP-OUT: July 22, 1986
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Judith T. Terry"."--
Southold
erry fSouthold Town Clerk
DATE: September 8, 1986
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�FFO1,r
Town of SoutholdCQG Application No.31
Judith T. Terry, Town Clerk Y .� , Residential
Town Hall, 53095 ,Main Road
P. O. Box 1179 �� ' .' Non-Residential
Southold, New York 11971 O t44` 0 •�`
Telephone _o.( ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
- Operation Permit No. _Ye."
Fee $ /D °G
DATE
OWNER NAME: (PliC-s-L fC pc)s fie;
OWNER MAILING ADDRESS: 69C Pimvo,4 Jf 406-•
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OWNER PROPERTY ADDRESS: E74-4 4fS V
OWNER TELEPHONE NUMBER: 73 f-
TAX MAP NO. : Section /0 3 Block 7 Lot 7. /
CROSS STREET: / s i S L�
TYPE OF SYSTEM: Septic Tank " New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7, - '2-
LOCATION
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.)
-
Signatur of Ap.licant
RECEIVED
Town rk's Office
DATE:
SEP 081986
Town Clerk Sootholc1
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