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Town Hall, 53095 Main Road
. ,�r" P.O. Box 1179
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►- Southold, New York 11971
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JUDITH T.TERRY ®��.,�ii�,r' ,'/ 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. 1038-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LA GREGO, JOHN AND KATHLEEN
Mailing Address 1 P. O. BOX 1425
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 5025 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5794
Tax Map No. section 79.00 block 3 lot 19.000
Cross Street SHIPS DRIVE
Date Of Last Pump Out 8/00/87
Issue Date: 3/03/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK VFOU."
•� -T&wn of Southold , c s ,. CQG', Application No. /6 3f
Judith T. Terry, Town Clerk - �. ;-= y
Town Hall, 53095 Main Road Residential
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P. O. Box 1179 � s� �i �• Non-Residential
Southold, New York 11971 O,y�
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Telephone 46: .(
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE ir�
OWNER NAME."---.1<--------4-rj
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OWNER MAILING ADDRESS: ta
ckL t(Q,rlj
OWNER PROPERTY ADDRESS,: - 'V\( 1`LO d 1 J I
JAI (-11 -L 0
OWNER TELEPHONE NUMBER: J`i
TAX MAP NO. : Section 1 q . Block Lot I
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
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Cesspool V New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: g
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.)
47
Signature of 'I;.plic.nt
RECEIVED BY: - vA/ /--et/—,--
wn Clerk's Office
DATE: io-