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JUDITH T. TERRY � j; Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER 0 Fax (516) 765-1823
`V- �! 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. 1983-R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
New Existing X
Name Of Owner FUSCO, NANCY T. & FRANCIS M.
Mailing Address 1 P.O. BOX 1213
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 6560 N. BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1868
Tax Map No. section 79.00 block 7 lot 2.000
Cross Street JACOB'S LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/05/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY / Town Hall, 53095 Main Road
TOWN CLERK S ® P P.O. Box 1179
REGISTRAR OF VITAL STATli;TICS Southold, New York 11971
MARRIAGE OFFICER Fax o Fax (516) 765-1823
®. ��®.i-%71Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1983-R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
New Existing X
Name Of Owner FUSCO, NANCY T. & FRANCIS M.
Mailing Address 1 P.O. BOX 1213
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 6560 N. BAYV I EW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1868
Tax Map No. section 79 block 7 lot 2
Cross Street JACOB'S LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/05/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'c�VFFOUrI"`
`-1/4u Town of Southold N� {. . CQG- , Application No. l / f3
Judith T. Terry, Town Clerk ��� : ,- k:: .4%) $10.00 - Residential
Town Hall, 53095 Main Road ,
P. O. Bo>i 1179 x; c.` `
�� -- ��} ,�� $25.00 - Non-Residential
Southold, New York 11971 O ®: �$
Telephone 4°/.41-(' %N-• ./
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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 $ •
DATE /n -S---9 D-
OWNER NAME: Pogljefil / ,03 /0 . s(i.,
OWNER MAILING ADDRESS: P(.0 . &X /0--/3
600' c-sb ,11 //Q7 /
OWNER PROPERTY ADDRESS: (�'S ,O ' ( LB,* ,; v,,,,
s 601-7-to�-7 / 0 9 1/q7 I
OWNER TELEPHONE NUMBER: 640 — 76S-- /86 r (Luot...167--a0
TAX MAP NO. : Section 9 Block 7 Lot___,____
CROSS STREET: 00155 Li9/,/
TYPE OF: SYSTEM: j Septic Tank New Existing //'--
Cesspool //` New Existing
Residential !� Non-Residential
DATE OF PREVIOUS PUMP-OUT: - ...... y...1•%:.Y ,
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.)
,q(4,,,tx.4/0P' /')/ • 4,1f3 61,
Signature of Applicant
RECEIVED BY.:_-. , V" �� �,
To n Clerk's Office
DATE: /Q 1-1
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