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JUDITH T. TERRY �,� j `s _ Town Hall, 53095 Main Road
A,"-',!4.4., i P.O. Box 1179
TOWN CLERK +a -
® . �1 Southold, New York 11971
REGISTRAR OF VITAL STATISTICS � � . �
MARRIAGE OFFICER , ��� Fax (516) 765-1823
® //4).% 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. 1729-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LEOGRANDE FAMILY IRREVOCABLE TRUST
Mailing Address 1 THE WINDSOR BUILDING
Mailing Address 2 80 WINDSOR AVENUE
City St Zip MINEOLA NY 11501-0000
Property Address 1 WEST MILL ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-746-5900
Tax Map No. section 106.00 block 9 lot 3.000
Cross Street MILL ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/29/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'.I
OFFICE OF THE TOWN CLERK �c�fFair
Town of Southold CQG'; Application No./'7 ,.
Judith T. Terry, Town Clerk :4;:::::46
Town Hall, 53095 Main Road I $10.00 - Residential
P. O. Box 1179 t74 $25.00 - Non-Residential
Southold, New York 11971 O ` . 4-`'r
Telephone
(516) 765-1801 =01
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
•
Fee $
DATE 71I /.
•
,
OWNER NAME: , rig i t ) X L .
OWNER MAILING ADDRESS:
�O NrJ D.SOR nue M INEO1K1. N.1 i i OI
OWNER PROPERTY ADDRESS: Nrjes-r }' fLL ROFlO
M r-rri TUo< N./
OWNER TELEPHONE NUMBER:_________________________________
TAX MAP NO. : Section `06 Block J Lot 2
CROSS STREET: -/i,7/ e4 +
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool Di4. New Existing DC
Residential y Non-Residential
DATE OF PREVIOUS PUMP-OUT: #0 f Ay,.i/,,I%
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.)
1. Oh Atr. / , .
S7nature- of Applicant
RECEIVED BY: $ j -
Town /Clerk's Office GANA
DATE: —0ZJUL 29 19P1
Town ark bung
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