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IS 1'1; �'' Town Hall, 53095 Main Road
P.O. Box 1179
__ ®7O/ Southold, New York 11971
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JUDITH T.TERRY „ii�i���, 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. 10614-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner GLORIA, ANTHONY
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip ORIENT NY 11957-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip ORIENT NY 11957-0000
Owner Telephone No. 516-323-3531
Tax Map No. section 18.00 block 5 lot 15.001
Cross Street TABOR ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/30/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK S\FFO(,r =
Town of Southold � CQG' Application No. /W61
Judith T. Terry, Town Clerk .� rY _ y
tZ
Town Hall 53095 Main Road fl-.4k '° Residential
P. O. Box 1179 FA T` : Va. i ` Non-Residential
Southold, New York 11971
Telephone1#O.(• ��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
• ,for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE .3— .�
OWNER NAME: /4/7d -y 9/ 4'
OWNER MAILING ADDRESS: /idH A d,41.c✓
OWNER PROPERTY ADDRESS: 02/g-4/111, N. . � %� 7
OWNER TELEPHONE NUMBER: fie 3.1 3 /
X TAX MAP NO. : Section /7— -I' Block /.f Lot /
CROSS STREET: (5;ti ,14,4) - kgs/ e / %,boa �cI
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool Y New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: �eC e - /12
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.) •
Si•,".ture of Applicant
RECEIVED BY: Tc-c..--)cw�.
Town Clerk's Office
DATE:
MAR 3 u 1989
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