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JUDITH T. TERRY �� Town Hall, 53095 Main Road
TOWN CLERK � � � P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �� T ��� Fax (516) 765-1823
4 �ss Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1644-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BONDARCHUK, HARRY
Mailing Address 1 26 MIDDLETON ROAD
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 26 MIDDLETON ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1247
Tax Map No. section 40.00 block 5 lot 26.000
Cross Street WASHINGTON AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 3/14/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFtilCff45F THE TOWN CLERK \FFU
T,own of Southold NQS ,_ `� ea,:- Application No. /�' �/
_fir-;'sem: . s .
Judith T. Terry, Town Clerk - y
�a f' .G%) $10.00 - Residential
Town Hall, 53095 Main Road �. +r : -
P. O. Box 1179 T. t fi N. 7Z $25.00 - Non-Residential
Southold, New York 11971 O .:® - O��`
Telephone 0( ^N /
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE A-2-- ' L7/
OWNER NAME: -.a/9-Z_ ,- r /Ar, I—Jc)4 .
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OWNER MAILING ADDRESS: /rite-41444 il
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OWNER PROPERTY ADDRESS : ,._,2‘ Pn y , A'�
OWNER TELEPHONE NUMBER: — ,q7—A-2-,Z-7
TAX MAP NO. : Section // Block Lot
CROSS STREET: Ze_<414/� - yj
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool L New Existing
Residential t-----/ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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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16
ature of Appant
RECEIVED BY:
Town Clerk's Office
DATE:
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