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,�� Town Hall, 53095 Main Road
ro O ®� �� P.O. Box 1179
,sem �i!� Southold, New York 11971
JUDITH T.TERRY ®�
4w.,����� � FAX(516)765-1823
TOWN CLERK FAX
(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. 1125-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BONDARCHUK, ALEXANDER
Mailing Address 1 325 RICHMOND ROAD
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 325 RICHMOND ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3661
Tax Map No. section 51 .00 block 6 lot 21 .000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/77
Issue Date: 5/25/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
IIS
OFFICE OF THE TOWN CLERK 'c�VVFO(��'-
Town of Southold Q C'
OG; Application No. II aS
Judith T. Terry, •Town Clerk
Town Hall, 53095 Main Road 8n' r` ) Residential ,x
P. O. Box 1179 Non-Residential
Southold, New York 11971 O � $
Telephone ..(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ l0v
DATE
----OWNER NAME: /"-i0 WD / Ai/ P ca-/Uf
OWNER MAILING ADDRESS: 3 J Pfc.-Nano/Up 1W
£un1O1 / ( eke Y 1(97/
OWNER PROPERTY ADDRESS: SA-, 4-S /Pao &-
OWNER TELEPHONE NUMBER: 766 366/
TAX MAP NO. : Section ,,6 Block 6 Lot .21
CROSS STREET: tCl/410A/ ki-
TYPE OF SYSTEM: Septic Tank New Existing )‹
Cesspool x New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: J it17/04.--- /4/ o`?. y/eS.-
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.)
4/.
Signature of Applicant
RECEIVED BY:
ewn Clerk's Office
DATE: V 5 m,..
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