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Town Hall, 53095 Main Road
;_� \-• �►IP.O. Box 1179
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JUDITH T. TERRY '",�v., I" 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. 1080-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CIERACH, VICTOR
Mailing Address 1 1280 JOCKEY CREEK DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000 .
Property Address 1 1280 JOCKEY CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3317
Tax Map No. section 70.00 block 5 lot 15.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •
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Town of Southold .OHO -, yrC�G Application No. /0f0
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road Residential ,/
P. 0. Box 1179 v' "} _< :- n ; Non-Residential
Southold, New York 11971 O�y,� �0� ��S
Telephone 1 ''
(516) 765-1801
TOWN ,OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. N..
Fee $
DATE / lCe l/Y 2i /9,=,
(1)1e,Rac___,kI
OWNER NAME: ViG16R
OWNER MAILING ADDRESS: /:,.go Tc--.3c_kev Cjiqreg.
�So0710 id, N.y 1/ 97/
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OWNER PROPERTY ADDRESS: 9/1-PiR
OWNER TELEPHONE NUMBER: ,3-&) - 7€ 3 3317
TAX MAP NO. : Section 0 Block *A ,5® Lot /,j
CROSS STREET: )"7f //1/ R04 d
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /7) f=r. 7 r vv, e
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 o pplicant
RECEIVED B •_._,_! E,-
,1:%-i; awn Jerk's •ffice
DATE: An 12 1939
Wilirrile
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