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JUDITH •
T.TERRY ,/ _l t Town Hall, 53095 Main Road
TOWN CLERK y % P.O.Box 1179
REGISTRAR OF VITAL STATISTICS
.. '�$ Southold,New York 11971
MARRIAGE OFFICER y� �- �1� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER of jigad Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER 4"
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3473-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner BUCZAK, STEPHEN
Mailing Address 1 P. O. BOX 393
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 470 WILLIS CREEK DRIVE .
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-734-6258
Tax Map No. section 115.00 block 17 lot 11 .000
Cross Street MEADOW BEACH LANE
Issue Date: 5/21/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFIf OF'THE TOWN CLERK 'c
i3IFD(,t
-' . Town of Southold . 4 --v Application No. V3 /�7
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road ' -4 $10.00 - Residential !�
P. O. Box 1179 to 'r ;' $25.00 - Non-Residential
Southold, New York 11971 IG
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Telephone = 1 [
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
, SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE Y-- /-- 7 ‘ '
OWNER NAME: X74-4---,,F-"•-/ /-, C/G 2 --9/C_
OWNER MAILING ADDRESS: A? .. 0 .g- J i3
7)7 4--1-1-/7zvc-./ )' /7 f5
OWNER PROPERTY ADDRESS: Y70 //</S C,e .t61, /c,-/c
-,,"i i 'Ai ,7L- Y Z//e A-/-/ -5`o
OWNER TELEPHONE NUMBER: 7/1— ,J/'r-56 /b,r d'-2-3-.-&
TAX MAP NO. : Section //Fo0 Block /7 Lot // ° `'
CROSS STREET: .227/1,-,9641 4 -e-, } �/`c-
TYPE OF SYSTEM: Septic Tank yr New Existing
Cesspool New Existing
Residential Xe Non-Residential
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.)
I
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/ ignature of Applicant
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