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JUDITH T. TERRY , kvitzF
Town Hall, 53095 Main Road
TOWN CLERK __ P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS `a '41A ifFax 516 765-1823
MARRIAGE OFFICER
`1 $' 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. 1626-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GAMBINO, ANTHONY
Mailing Address 1 1450 LUPTON POINT ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1400 DEEP HOLE DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4796
Tax Map No. section 115.00 block 12 lot 19.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/90
Issue Date: 2/20/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFIGE OF THE TOWN CLERK �FFD(,r��'
Town of Southold O .. 11Q -- Application No. /,0'9,6
Judith T. Terry, Town Clerk 4 0 :�
Town Hall, 53095 Main Road $10.00 - esidential
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P. O. Box 1179 �t � � � �` $25.00 - Non-Residential
Southold, New York 11971 O -41,
Telephone �j • '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
forfor
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
OWNER NAME: 47/7/1Q/V�/ (�j'�// /// 7 •
OWNER MAILING ADDRESS: // 1-0 /_ ///7 4/ Pe/,;/7 , / /�,
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OWNER PROPERTY- ADDRESS: /144/ 65-- /104 D. ,.1-(;QE.
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OWNER TELEPHONE NUMBER: o2 7,17_ 97 '6 L D b /-7/f-- 3.2 4 3o Jt
TAX MAP NO. : Section ✓/kr Block %o. Lot /7
CROSS STREET: 4 CrJ .Sc�F/ ✓/� ,' O -
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: jp
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 re of Applicant
RECEIVED BY: y .eiccec� airr
Town I Clerk's ffice
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DATE:
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