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Town Hall, 53095 Main Road
VO P.O. Box 1179
94®� sz �' Southold, New York 11971
JUDITH T.TERRYi 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. 1362-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MARTINEZ-FONTS, ALFONSO
Mailing Address 1 3436 TWISTED OAKS
Mailing Address 2
City St Zip SAN ANTONIO TX 78217-0000
Property Address 1 115 WEST COVE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 512-590-4870
Tax Map No. section 111 .00 block 3 lot 2.000
Cross Street HAYWATERS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/11/90 Judith T. Terr
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �FFO r3�
Town of Southold Q� :_. 6J Application No.
Judith T. Terry, Town Clerk • �' °�^'
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$10.00 - Residential
Town Hall, 53095 Main Road � "�� t-44-:4! $25.00 -
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P. O. Box 1179 yy � $25.00 - Non-Residential
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Southold, New York 11971 O
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 ,
DATE /2/zM1
'OWNER NAME: 4/- ) (O /1(-0-4)1/2-C2-- 6
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OWNER MAILING ADDRESS: 3Y36 y�j /J7 c/ ( Ls"c h 4-)1-1173-7,/a 7f-2-/7
OWNER PROPERTY ADDRESS: //J /J- 65-1)4.-65-1)4.- Ree
C�(�T640,, v-C
OWNER TELEPHONE NUMBER: S71 .S O 24-70
TAX MAP NO. : Section ///i Block 3 Lot 2-
CROSS STREET: /i,,t l - >Ge
TYPE OF SYSTEM: Septic Tank I./ New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ///9
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.)
Sign of Applicant
RECEIVED BY:
Town Clerk's Office "
DATE: - - - -
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