HomeMy WebLinkAboutMandaro B) tot; 7` : Town Hall, 53095 Main Road
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® �! P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ' ®�
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. 1267-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MANDARO, NICHOLAS
Mailing Address 1 167 BACHE AVENUE
Mailing Address 2
City St Zip STATEN ISLAND NY 10306-0000
Property Address 1 BAY AVENUE
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 718-351-8960
Tax Map No. section 31 .00 block 16 lot 7.000
Cross Street HUCKLEBERRY LANE
Date Of Last Pump Out 0/00/74
Issue Date: 10/12/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLEI(K S\FFOUrr,'
Town of Southold •�� Application No. /afo /
Judith T. Terry, Town Clerk rtn'w y
Town Hall, 53095 Main Road �,�, :.0 $10.00 - Residential
P. 0. Box 1179 cn 4.� i ; $25.00 - Non-Residential
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Southold, New York 11971 4 ® -� OSP
Telephone ( `�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 0C-1--- ( 2 ff rp
OWNER NAME: AJ! CkoC /1(44,,4,0 •
•
OWNER MAILING ADDRESS: / ff:01C7 Arc '
,t/,y /O30-
OWNER PROPERTY ADDRESS: Z /%LlCLQ ,216"- 7
41260 t.)
OWNER TELEPHONE NUMBER: 711- 7 ?60
TAX MAP NO. : Section 3 / Block /6 Lot 7
CROSS STREET: /gut CI.Ce Dtd Rr
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool 1 New Existing
Residential Non-Residential
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.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
RC I
DATE:
OCT 1a1k �
Tow Clerk Southold
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