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JUDITH T. TERRY F Town Hall, 53095 Main Road
P.O. Box 1179
TOWN CLERK
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
$r Fax (516) 765-1823
MARRIAGE OFFICER ® 0 ��� '.
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(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3043-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BORAWA, MINNIE
Mailing Address 1 P. O. BOX 83
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0083
Property Address 1 4885 COX'S LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6858
Tax Map No. section 96.00 block 2 lot 9.000
Cross Street ROUTE 48
Date Of Last Pump Out 0/00/00
Issue Date: 6/25/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
o
OFFICE OF THE TOWN CLERK S\\FFOCA-
Town of Southold4(0::
�� CQ Application No. d �-
Judith T. Terry, Town Clerk . 4 ; : .:
Town Hall, 53095 Main Road
:.- .G 7 $10.00 - Residential
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P. O. Box 1179 crs t:1'; '' $25.00 - Non-Residential
Southold, New York 11971 OO r}` �0���`
Telephone , 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE JUNE Igo lqq3
OWNER NAME: MRS- f's4 f 13 A
OWNER MAILING ADDRESS: Pso , Box_ $3
C UTCHo&tJ P/1y. 1193.'- 0083
OWNER PROPERTY ADDRESS: - L-g g 5-- C o Xi5, l A N E _ -
C UTNHO c U E, f 035
OWNER TELEPHONE NUMBER: ( 1 4o ) 73 L - ( gs6
4738$9
TAX MAP NO. : Section q ( Block 2.. Lot
CROSS STREET: ' Q U '7 E 4* 8
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: N 1\N'I YEARS AGO
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.)
fJl�
Signature of Applicant
g
RECEIVED BY:
Town Clerk's Office
DATE:
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