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JUDITH T. TERRY
® �� t Town Hall 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765-1823
44
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. 3068-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner IZZO, ANTHONY R.
Mailing Address 1 7 WEST MUIRFIELD ROAD
Mailing Address 2
City St Zip HOMOSASSA FL 34446-0000
Property Address 1 1420 PINE TREE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6596
Tax Map No. section 98.00 block 1 lot 20.000
Cross Street HORTON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
o
OFFICE OF THE TOWN CLERK �FFO 6
Town of Southold �% ; eQ Application No.3� U Y
Judith T. Terry, Town Clerk ‘ ......0--- ,r-" 1 �',
Town Hall, 53095 Main Road ;,; $10.00 - Residential
P. O. Box 1179cr3 re. ?3{ ' �.` $25.00 - Non-Residential
Southold, New York 11971 O �; •*�'
Telephone : ( Y► ,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ C'
DATE 3 %Al , a /4J
OWNER NAME: A6J'CO-(-an,t a . �2)_.,
OWNER MAILING ADDRESS: 1 tJc-c-c mu!(,,,f1 t-n GL;,Mf
1---Drtoskt4- 1 ar?,(0A- 3t-iLt 6
- OWNER---PROPERTY ADDRESS:. .1 1+),....0 Pular(.c;'1— ig-) - - t
Cvfiq-b6u 1 i)13,--
OWNER
1ez,®OWNER TELEPHONE NUMBER: 14-o H c, s, Es ,(qb+-/-) 3g,), --I-)71 <irrri d,j Ai,y, -73 y_..6 3-n
.
TAX MAP NO. : Section qY Block / Lot
CROSS STREET: s'dt'l_-rod re-Ja 4-6
TYPE OF SYSTEM: -Septic Tank ' New Existing
Cesspool New Existing 1/
Residential ' Non-Residential
DATE OF PREVIOUS PUMP-OUT: 6:7Eva`J
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 oLAplicant cia
Oc
RECEIVED BY:
Town Clerk's Office '
DATE: -2/d //F3
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