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JUDITH T. TERRY 4,3m < Town Hall, 53095 Main Road
TOWN CLERK • #� xi . +r,�, 8 P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICSVI * FaX (516) 765-1823
MARRIAGE OFFICER ��: � @� 1%
'` 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. 1580-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DIACHIN, THEODORE L.
Mailing Address 1 P. O. BOX 61
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 PECONIC BAY BOULEVARD
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-4013
Tax Map No. section 127.00 block 8 lot 17.000
Cross Street NORTH OAKWOOD ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C.\\FFO(,r . Q�
Town of Southold • 4 -- Application No. 1 SU
Judith T. Terry, Town Clerk . ig ;4'» .�►
Town Hall, 53095 Main Road -< $10.00 - Residential
p. O. Box 1179 v' $25.00 - Non-Residential
Southold, New York 11971 OO �0�'
Telephone (
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ � � o e
DA 3d d
T 7P7
'OWNER NAME: •
OWNER MAILING ADDRESS:_ 16.
ANPrziy
OWNER PROPERTY ADDRESS:A/4
l_ /4 �
/5
OWNER TELEPHONE NUMBER: c2
TAX MAP NO. : Section /0271 Block Lot /7
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool r// New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: a
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 o Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
NOV O 51990
T®wn Clerk Oaddidd