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clsrin Town Hall, 53095 Main Road
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P.O. Box 1179
--1454/ IP,r' Southold, New York 11971
�% iir//iill1 FAX(516)765-1823
JUDITH T.TERRY 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. 1541-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ROMEO, NANCY AND STEVEN
Mailing Address 1 515 MAYFLOWER ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 515 MAYFLOWER ROAD
• Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5468
Tax Map No. section 107.00 block 8 lot 22.000
Cross Street WESTV I EW
Date Of Last Pump Out 0/00/00
Issue Date: 10/02/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c„VFFO(,(r�'-
Town of Southold � CQG�• Application No. 75-2//
Judith T. Terry, Town Clerk . t''
Town Hall, 53095 Main Road t!'3 = $10.00 - Residential 1Z
•
p. O. Box 1179 �• $25.00 - Non-Residential
Southold, New York 11971 OO ;'" .1�Oy�'�`•
Telephone j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /oOO
_
DATE 61-p7 1 -qd
'OWNER NAME: 4,410 C yl -- EX-1 aCY ?C Q
OWNER MAILING ADDRESS: 5;i rhig / 'LObthe.„-
M rm L, KfLy #9.
OWNER PROPERTY ADDRESS: a$t')
OWNER TELEPHONE NUMBER: i.,z9 1
TAX MAP NO. : Section /® 17 Block Lot 7
CROSS STREET: //I/ EST
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: 76
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.)
S/gnatu"re of Applicant
•
RECEIVED BY: J
Tom( Clerk' Office _ .- - -DATE: - , ".