HomeMy WebLinkAboutFior ��� 4,
Town Hall, 53095 Main Road
P.O. Box 1179
04
H - !� Southold, New York 11971
JUDITH T.TERRY %' FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1451-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner FIOR, GILMO
Mailing Address 1 82-16 60TH AVENUE
Mailing Address 2
City St Zip ELMHURST NY 11373-0000
Property Address 1 3015 PEQUASH AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 212-639-4963
Tax Map No. section 103.00 block 12 lot 10.000
Cross Street HOLDEN AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 5/07/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.
OFFICE OF THE TOWN CLERK • •c3\\V
Town of Southold Q C' = Application No. -
Judith T. Terry, Town Clerks==
�►Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179u' 0'4
• � rte, �, �. ��, $25.00 - Non-Residential
Southold, New York 11971 O ® *-J
Or ••
Telephone I ' %‘6 •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.__
Fee $ lb
DATE gibtl/ d
OWNER NAME: (G.IM0 FQ9te •
OWNER MAILING ADDRESS: �d— /6 60 i / )L))
-fit e-of CRs i/ ``i?
OWNER PROPERTY ADDRESS : /5- /616-41149]
C v 'Hr)Sgb.j ,Gv/ /173,
• OWNER TELEPHONE NUMBER: .2/.2— 67391 2/963
TAX MAP NO. : Section 03 Block ) 2-- Lot 10
•
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool I New Existing V
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,)
7_,kij-e"410
Signature of Applicant
40 glib&
RECEIVED BY: *4k-0 / ' .001. _v
Town C -rk' . Of ice
DATE: (S gd
• N4 0 g.
30 i PEQuAs+l AVE
ZPh)GUE tJ'/ 1193 ' -
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