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Town Hall, 53095 Main Road
�; ����'. P.O. Box 1179
=_i ss� �i� Southold, New York 11971
JUDITH T.TERRY ®1" TELEPHONE
TOWN CLERK (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 809-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner BARON, ZYGMUNT AND WIFE
Mailing 'Address 1 MAIN ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5306
Tax Map No. section 109. 00 block 1 lot 14. 000
Cross Street ALVAH LANE
Date Of Last Pump Out 6/17/87
Issue Date: 9/02/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK sa
Town of Southold Q h eaG� Application No. R6V9
Judith T. Terry, Town Clerk �� Oze
" - Residential
Town Hall, 53095 Main Road o „� 1
P. O. Box 1179 ' OxtV'°` ri � Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. S'®
7__--
Fee $ J O_ 12-6
DATE V.-3 /7.0gi
OWNER NAME: ��� Y-
OWNER MAILING ADDRESS: C 164k,( _Q ,` t
7.4 -74
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: _S-76 r 7.354"—r50-6
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TAX MAP NO. : Section c_ �, Block Lot j T
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New --)Am Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: G -e--1 / 7 /q r�
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.) •
'•.nature of Applicant
RECEIVED BY: ' 2.14 ����
ow Clervk s tffice
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DATE: 7
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