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ELIZABETH A.NEV I LLE 1tt�� % Town Hall, 53095 Main Road
TOWN CLERK t ® ,4y. "' 7 : el%, 7.4 P.O. Box 1179
g ` " Southold New York 11971
REGISTRAR OF VITAL STATISTICS ,�� '
MARRIAGE OFFICER �0 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER ® •® •�� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ���
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3785-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner LEOGRANDE FAMILY IRREV. TRUST
Mailing Address 1 80 WINDSOR AVENUE
Mailing Address 2
City St Zip MINEOLA NY 11501-0000
Property Address 1 4900 WEST MILL ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-746-5955
Tax Map No. section 106.00 block 6 lot 8.000
Cross Street NAUGLES DRIVE
Issue Date: 4/23/98 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF TIlE TOWN CLERK COF
TOWN OF SOUTHOLD &, OG Application No.
ELIZABETH A.NEVILLE,TOWN CLERK a : • $10.00 - Residential
P.O.BOX 1179 Er3 -
SOUTHOLD,NEWYORK 11971 "``�' `' ° ' ' $25.00 -, Non-Residential
Telephone *0 %pc
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE k,`/ �o� /7/f
OWNER NAME: to 6 J � P ,a 4,14j /
OWNER MAILING ADDRESS: /0 ,/fes/,,. , ,G
/1//dt r.94 44 //X
--- OWNER PROPERTY ADDRESS: 47OO L 14//
/"//VAY::g. / r /n'c2
OWNER TELEPHONE NUMBER: (,i/GJ 774' -5 i •
TAX MAP NO. : Section/Of _-- ? Block Lot
CROSS STREET:
' I �A-r�� .r Aver
TYPE OF SYSTEM: Septic Tankc - V New Existing
Cesspool 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.)
na re of Applicant
tECEIVED• BY: - --
Town
-
Town Clerk's Office
DATE: -
•
2.
4 I
OWN OF SOUTHOLD
,,�,Q�oSqEF co , u
i N Ticket No:-, ii459,8 ,
I,
SCAVENGER W TE REPORT =
Name of Hauler • l Load @ . _ .. , ,�O���lons -`
Permit No. ' � , ❑ Half Load @ Gallons--Truck Capacity .. J Full
$ Paid' '
`:-'' (dote), .' -
' LOCATIO : 0 Sp it load @ Gallons
_ r r (Validation of.Paymeni)'
New ❑ Re eat ,�Q/V „ ..
, ,, ,
?2_,.., , .sme of Owner p. [[
,i-P W(AdeZ--- ' ,
Stree ' 4� '1A-)4'.44 -1/4)1%e#' . . ., -
Hamlet
Telephone No. i� Tax Map NoM4
Cross Street' -
L '' 'DIAGRAM (Locate buildings nd cesspool/septic system and approximate-distance in-feet:./` ' ,
'between buildi gs and sys ep•give rth`arr .) .'n• ,
, ..._._._..._._y )f ..ov .
,
, ... I i la , ,. ,
:.
I hereby certify that the above riginated within the Town of Southold/Town of• Shelter Island '' . '
at the above location,and to he best of my knowledge contains no chemicals;Hazardous,or ,
toxic wastes. False statements made herein are punishable as a misdemeanor'pursuantto
' . Section 210-45 of the Penal Law of the State of New York, and may result in my arrest and the •
impoundment of the vehicle 1 driving. r
Name of Driver
J
` Signature of Driver..1
Received b f �. i h t,• f
1 -- Date ....e- 7. � ime 1Q..t..SO , .,. t'
(n" reatmeni Plant '.