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JUDITH T. TERRY j Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS `(J 11 Southold, New York 11971
JO' Fax (516) 765-1823
MARRIAGE OFFICER
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MARRIAGE
it 4 Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1748-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CYBULSKI, ANDRE
Mailing Address 1 300 MIDWOOD ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 300 MIDWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6586
Tax Map No. section 103.00 block 14 lot 7.000
Cross Street EASTWOOD DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 9/10/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OfTHE TOWN CLERK sSVFFU(,,('
'ti Town of Southold �� ..- CQG Application No. /7 kis--
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road - -< $10.00 - Residential,
P. O. Box 1179 Ln s
cn �. . �rya,����. � $25.00 - Non-Residential
Southold, New York 11971 f �
Telephone = j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TAN,K or CESSPOOL
Operation Permit No.
Fee $ •
DATE q 9(
OWNER NAME: /9/p,},e
OWNER MAILING ADDRESS: 3®a 76Zeitoezi
.4,20 0,1 3
OWNER PROPERTY ADDRESS: 3e,6 �db��d ,A
e/.L 7e A/ C- � , A/7/ //?a,5 '
OWNER TELEPHONE NUMBER:
',TAX MAP NO. : 'Section /43 Block /1-71 Lot
CROSS STREET: 439-,57-14/66.6 2).ei✓e-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7/2 S/7/
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.')
(74441_
Signature Applicant
RECEIVED BY: .
own Clerk's Office .
DATE: 7 / /° /9/
property lines. Give street and block number or aesc „ ,,4.,.,,L4111y ,., UGI,, ,GG, ,,.,11, U11,4 ,,,,,,,,.,_
whether interior or corner lot. SO
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