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HomeMy WebLinkAboutRusso, Donald •,�%pF SO(/l0 - ELIZABETH A. NEVILLE o�,`O l0 Town Hall, 53095 Main Road TOWN CLERK 4 4; P.O. Box 1179 REGISTRAR OF VITAL STATISTICS co Southold, New York 11971 MARRIAGE OFFICER �,ct'A Fax (631) 765-6145 RECORDS MANAGEMENT OFFICER =4l� ^�1 oo Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER = CQU�y* t southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 4353-R Residential X Non-Residential Fee $ 10.00 New Existing X Name Of Owner DONALD RUSSO Mailing Address 1 770 VILLAGE LANE Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 SAME AS ABOVE Property Address 2 City St Zip 00000-0000 Owner Telephone No. 631-298-1014 Tax Map No. section 114.00 block 6 lot 1.700 Cross Street ROUTE 25 Issue Date: 8/17/07 Elizabeth A. Neville Southold Town Clerk (TOWN SEAL) �' .1. \ Town Hall, 53095 Main Road ELIZABETH A.NEVILLE � � TOWN CLERK P.O. Box 1179 aA Z Southold,New York 11971 REGISTRAR OF VITAL STATISTICS v. �f MARRIAGE OFFICER � Fax(631) 765-6145 RECORDS MANAGEMENT OFFICERID .� Telephone(631) 765-1800 FREEDOM OF INFORMATION OFFICER _ o'� 4. �a��i iosoutholdtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISTRICT APPLICATION OPERATION PERMIT CESSPOOL or SEPTIC TANK Residential @$10 ` or Non-Residential @$25 Application No.`3 S.35 Permit No. .5 57./ /e Owner Name ✓O AiQ'L v ! ... Owner Mailing Address 57-6 1l at-441 14Ale LTi/ 1-1) Ai)/ 1 9 Sa Owner Property Address i7 E AS R�o✓v Owner Telephone No. 6,y/ ` o2` $' /0 /' Tax Map No: .'Section //4. ao Block Lot ( ► Cross Street /Cd J-re ads- Please check each that applies: New Construction Alteration to Exis 'ng System ✓ Residential Non-Residential NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate building and system; give north arrow and approximate distance in feet from system to building and closest road. New construction may submit copy of survey with SCHD approval.) QVc-L,e.�C . g///4.(e) Signature of Applicant Date Received by: -7 1 Or-1 Do/vAL_p 2vs s� 446 Va.- LA-az. IAA/6 MArri-rucK /cry G L%S S /0c>a L /41.--7- - 47-rDe4 1-A m4P A/c gE i7o1 //41, Oa aGo�x. 4, La T fab , ,0 CA _. 1 1 -k/_ • w 1 � . .