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JUDITH T. TERRY ��' ` Town Hall, 53095 Main Road
TOWN CLERK
C:3 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971 ,
ry O Fax (516) 765-1823
MARRIAGE OFFICER 1
_®OM s\V �$!' 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. 1794-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner ANTICEV, MARKO
Mailing Address 1 1024 64TH STREET
Mailing Address 2
City St Zip BROOKLYN NY 11219-0000
Property Address 1 OLD NORTH ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 718-836-0656
Tax Map No. section 54.00 block 3 lot 26.002
Cross Street LIGHTHOUSE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 10/25/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •..
OFFICE OF THE TOWN CLERK
Town of Southold • , 0�� %. Application No. /7?
V
Judith T. Terry, Town Clerk }Re y
Town Hall, 53095 Main Road .< $10.00 - Residential
p. O. Box 1179 F 'y z $25.00 - Non-Residential
Southold, New York 11971 OO
Telephone : /421%
�► '�
(516) 765-1801
• TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ -
. DATE DG�, //ifs/
OWNER NAME: Marko Anticev
OWNER MAILING ADDRESS: 1024 64th Street
Brooklyn, N.Y. 11219 '
-OWNER PROPERTY ADDRESS: 01:d-Nci'rth Road -- - .
Southold, N. ., 11971
OWNER TELEPHONE NUMBER: ' 718-83.6-0656
TAX MAP NO. : Section 54 Block 3 Lot 26.002
.CROSS STREET: Lighthouse Road
TYPE OF,SYSTEM: -Septic Tank X New x Existing
Cesspool 1 New x Existing
Residential x Non-Residential
DATE OF PREVIOUS PUMP-OUT: New ,
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.)
7p, 6
Signature of Applicant
RECEIVED BY: ;
Town Jerk's Of ice -
RECEIVED -
DATE: - . . -
OCT 2F, 190
town Clerk.Southold
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