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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® .t+ P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .� Southold, New York 11971
G cl _ .Y Fax (516) 765-1823
MARRIAGE OFFICER ®va *8=4,0' Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1912-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner LORETO, JOHN
Mailing Address 1 14 COLONIAL DRIVE
Mailing Address 2
City St Zip SMITHTOWN NY 11787-0000
Property Address 1 795 GLEN COURT
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6456
Tax Map No. section 83.00 block 1 lot 8.000
Cross Street VISTA PLACE
Date Of Last Pump Out 0/00/00
Issue Date: 5/28/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'c0FD(.,r
Town of Southold �% - CQG', Application No. 7f/ t
Judith T. Terry, Town Clerk '-- k
�. _ L ) $10.00 - Residential
Town Hall, 53095 Main Road ,.4�a
P. O. Box 1179 cr3 '� ; .c' '` ' : $25.00 - Non-Residential
Southold, New York 11971 O Q±6 $3---:-
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Telephone = 1 r
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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
_Fee $ 16
DATE 2/"1-.
i 411/1
0 OWNER NAME: ---iR, /V 11AE�
OWNER MAILING ADDRESS: 114. _. j .; _r
4-Y1-4,1 _ 74/
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OWNER PROPERTY ADDRESS: - s '.. ec®�i1/4„)
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OWNER TELEPHONE NUMBER: '3 . j---,
TAX MAP NO. : Section 5.--S Block / Lot 7
CROSS STREET: 17/.5 7 i ( _
TYPE OF, SYSTEM: Septic Tank ---'7. New Existing 41. .
L..- ----
Cesspool
Cesspool New Existing
Residential Non-Residential
si i
DATE OF PREVIOUS PUMP-OUT:
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.)
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Signature of Applicant
RECEIVED BY: A ALe._____
Town Clerk's Office
DATE: 5 -7 l '
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