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JUDITH T. TERRY + �; s; f � I Town Hall, 53095 Main Road
TOWN CLERK �^ P.O. Box 1179
`: ` Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ;a "a -
MARRIAGE OFFICER �' Fax 516 765-1823
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. 1621-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DETRANO, SALVATORE M.
Mailing Address 1 5 WENDOVER ROAD
Mailing Address 2
City St Zip EAST SETAUKET NY 11733-0000
Property Address 1 5125 PECONIC BAY BOULEVARD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-751-6714
Tax Map No. section 128.00 block 1 lot 13.000
Cross Street BIRCH STREET
Date Of Last Pump Out 0/00/00
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Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
}Y
. OF THE TOWN CLERK '
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Town of Southold O� �G Application No. /& ,21
Judith T. Terry, Town Clerk fig' $10.00 - Residential
Town Hall, 53095 Main Road
p. O. Box 1179 cry $25.00 - Non-Residential
Southold, New York 11971 O ® 0�,��`
Telephone Q1 `��
(516) 765-1801 •
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0, 06
DATE � C�- /O
OWNER NAME:-CdJV4 e ..e. j/Ri frvo •
•
OWNER MAILING ADDRESS:) 6e.)-(2.444 -fit 4e
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z/0 33
OWNER PROPERTY ADDRESS : 572'5 1&i /
oeQ.u. Lee L7/0" Il-9 Y g.
OWNER TELEPHONE NUMBER c57,6) -7-1-/-10-7/4
TAX MAP NO. : Section /24)-" Block / Lot 43
CROSS STREET: /jkl c�(,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing .x
Residential 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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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