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JUDITH T.TERRY ` ® Town Hall,53095 Main Road
TOWN CLERK t k.• ¢� P.O.Box 1179
c) ; ,� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER %%
® �1 Fax(516)765-1823
•RECORDS MANAGEMENT OFFICER ^� 3 /
FREEDOM OF INFORMATION OFFICER / �� Telephone(516)765-1800
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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. 3350-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner IPPOLITO, NICHOLAS W.
Mailing Address 1 36 GEHRIG STREET
Mailing Address 2
City St Zip COMMACK NY 11725-0000
Property Address 1 235 CAROL ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-499-6360
Tax Map No. section 52.00 block 2 lot 7.005
Cross Street NORTH ROAD
Issue Date: 6/12/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �\\•FFOU, -
Town of Southold C'
�, OG;�, Application No...33
Judith T. Terry; Town Clerk �� y
Town Hall, 53095 Main Road chin ' • , $10.00-- Residential
-..• •
P. 0. Box 1179 c _. i �•'
Southold, New York 11971 ��� $25.00 - Non-Residential
TelephoneQ( *
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION -
• for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL ,
Operation Permit No.
Fee $ ,A9
DATE
-OWNER NAME: , `7/C4i /ppi'%a
OWNER MAILING ADDRESS: 3 /// <C� " $7' I
CD/i4AJftek., LB 7Z 5—
OWNER PROPERTY ADDRESS: - 2; A.'/pa5Z"
2; 35 C,g,aoRp _5; retie ,r ` `i 97/
OWNER TELEPHONE NUMBER: (37 )
4,7368 ? 5Z.-2-7. 57" .
TAX MAP NO. : Section Block' Lot
CROSS STREET:
TYPE 'OFSYSTEM: Septic Tank New Existing
Cesspool P"-°- New - Existing
Residential Non-Residential
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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Signature 74pplicant
R •
RECEIVED BY:
TowlattiNk Office
DATE: - JUN 5 1995
town Clerk Southold
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