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Town Hall, 53095 Main Road
4\c3 �� P.O. Box 1179
® �� Southold, New York 11971
JUDITH T.TERRY
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TOWN CLERK
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1394-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ZEBROWSKI, STEFAN & MARIE
Mailing Address 1 BOX 34
Mailing Address 2 BAY AVENUE
City St Zip EAST MATION NY 11939-0000
Property Address 1 BAY AVENUE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-0014
Tax Map No. section 31 .00 block 9 lot 9.000
Cross Street LAKEVIEW TERRACE
Date Of Last Pump Out 0/00/00
Issue Date: 3/01/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK `�c��FFO(,r"-' q
Town of Southold �% .,._ CQ -• Application No.-/39L/
Judith T. Terry, Town -Clerk .*).. 1;% . ..
Town Hall, 53095 Main Road u': - ', F+ : $10.00 - Residential yQ,S
P. O. Box 1179 cn it. .. l: i
. ...,..._.:.14,.,74,,., �; $25.00 - Non-Residential
Southold, New York 11971 ,-,u-61.Qs' 4'..1 ;- ;.K
Telephone / . 0
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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:for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.' . -
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Fee $ 1 o„ u ® • .
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. DATE V— 3 A 1 O
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'OWNER NAME: .� 7'E 'f Ai -4- I14if 1,'e_ 2-RA) •bio ws--kt' • .
OWNER MAILING ADDRESS: `113'ex 3Y owv A-v-e' . 6-r 4,e;;,v dvy,,
V9,79-
OWNER PROPERTY ADDRESS: ,$0 0A l" AVG. #169" NA/oat-Ai 4 J-
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OWNER TELEPHONE NUMBER: 1i4v 9 9 7 r- CO 0 94/
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TAX MAP NO. : Section 3/ Block ' 7 Lot F
CROSS STREET: 5 Ave, 14h d .e vi .' -�;�iyz;Qcsz-
TYPE OF_SYSTEM: Septic Tank ' - - New Existing
Cesspool >r .eS New Existing y,es
Residential .,e„g Non-Residential .
DATE OF PREVIOUS PUMP-OUT: ''"g9 — -,,. — 4?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 closest road.)
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Signature oat plilEant
RECEIVED BY: ��
- ' T wn Clerk's Office
DATE:
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