HomeMy WebLinkAboutDioca ieef
fir ;
1,0
Town Hall, 53095 Main Road
• P.O. Box 1179
��®� ,i� Southold, New York 11971
tai
JUDITH T.TERRY
< tz/�!I'I FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1461-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner DIOCA, PETER F. AND MARGARET E
Mailing Address 1 P. O. BOX 1303
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 2120 KENNYS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5345
Tax Map No. section 59.00 block 3 lot 12.000
Cross Street CHESTNUT ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/17/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III
OFFICE OF;THE TOWN CLERK - ���FF��,�'-
'Town' of Southold ��Q Application No./V ,
� y
(
Judith T. Terry, Town Clerk � /VI „,,+-,;a^.
Town Hall, 53095 Main Road �, $10.00 - Residential
p, O. Box 1179 C•r3 6” ' $25.00 - Non-Residential
%Southold, New York 11971 O ® '' ' rtO�,••�`
Telephone *Q(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT -
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE /6 —5>c)
OWNER NAME: /99're/2 F /124/2 /eg:7- /3/06/9
OWNER MAILING ADDRESS: AO, /sox /303
OWNER PROPERTY ADDRESS: 2/2-® legit/A/ ,P0/9/J
OWNER TELEPHONE NUMBER: .624-765--6-81.15--
TAX
624-'GSSasTAX MAP NO. : Section 6-9 Block 3 Lot 0/2-
CROSS
/zCROSS STREET: ' „74A lQc2
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New I/ Existing
Residential k ' 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: , 'I
LL-4-7,--LQ
Town Clerk's Office
DATE: /(9 - 9d
a •
-s7-4/e/7-- 2o,-4,O
fJ
\ ,- -
t1
•
"-4!'
is
t: 4