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Town Hall, 53095 Main Road
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� P.O. Box 1179
=___ �T 70" Southold, New York 11971
JUDITH T.TERRY -�,,,,�ir'i'�• FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1382-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BARTOSIEWICZ, ALFRED
Mailing Address 1 17915 SOUNDVIEW AVENUE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 17915 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2979
Tax Map No. section 51 .00 block 1 lot 6.000
Cross Street MOUNT BEULAH AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/14/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK • .�,
Town of Southold FOUr
D = Application No. 3 Z ,
Judith T. Terry, Town Clerk fs
Town Hall, 53095 Main Road :?r I $10.00 - Residential
P. O. Box 1179 �; �-
,t � z $25.00 - Non-Residential
Southold, New York 11971 p '� ''s r° `
Telephone "�( 'I\4 o
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ l(;J °-�-•_.
DATE �3 /FG
'OWNER NAME: 1,1?ED 6/,1 e.57 o'/CZ
OWNER MAILING ADDRESS: / 7/ /5--
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OWNER PROPERTY ADDRESS: /7f/5 c1/7/ // YE •
>SD
77/0 /7917/
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OWNER TELEPHONE NUMBER: 7e, - 2977
TAX MAP NO. : Section S- J Block ' Lot
CROSS STREET: /w'
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential `✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6
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.)
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Signature of Applicant
RECEIVED BY:
own Clerk's Office
DATE: --// 3 / ( 6
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