HomeMy WebLinkAboutRistuccia 4-41
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` -1 Town Hall 53
�,, �y � 095 Main Road
ef® . ��. P.O. Box 1179
,I � .�� Southold, New York 11971
JUDITH T.TERRY '��rrriiliii��" FAX(516)765-1823
TOWN CLERK TELEPHONE(516)7654801
• 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. 1285-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RISTUCCIA, JOSEPH A.
Mailing Address 1 P. O. BOX 611
Mailing Address 2 -
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 3905 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-1111
Tax Map No. section 79.00 block 3 lot 10.000
Cross Street SHIP'S DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 10/30/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c0FO(A' -
0N�
Town of Southold L'QG` Application No.
Judith T. Terry, Town Clerk a4' ' ' ,
'� •'��°, �;� .0 $10.00 - Residential
Town Hall, 53095 Main Road --
p. O. Box 1179 n t Mefl �� $25.00 - Non-Residential
Southold, New York 11971 Kt)
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Telephone y►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 16 . 11
OWNER NAME: s--3 4 RISaU CCM
OWNER MAILING ADDRESS: IRO GI
.ecuA--0 AJ-1 . U cIf
OWNER PROPERTY ADDRESS: 39 124)
OWNER TELEPHONE NUMBER: S—B4 - 7G f jiI/
TAX MAP NO. : Section 7 Block ' Lot / 6
CROSS STREET: _S;4 /if'Sr�,'
TYPE OF SYSTEM: Septic Tank ' ,New Existing
Cesspool New Existing
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.)
fr
Signature of Applicant
RECEIVED BY:
own Clerk's Office
DATE: /0 9 l/ ��
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