HomeMy WebLinkAboutRusso, Donald •,�%pF SO(/l0
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ELIZABETH A. NEVILLE o�,`O l0 Town Hall, 53095 Main Road
TOWN CLERK 4 4; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS
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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
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