HomeMy WebLinkAboutPagoto ._
. tri .� Town Hall, 53095 Main Road
®�- P.O. Box 1179
'y®1 `��,�� Southold, New York 11971
JUDITH T.TERRY � ,,ir�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. 1565-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PAGOTO, ANTHONY S.
Mailing Address 1 50 ROOSEVELT STREET
Mailing Address 2
City St Zip GARDEN CITY NY 11530-0000
Property Address 1 BAYBERRY ROAD
Property Address 2 NASSAU POINT
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-437-8520
Tax Map No. section 111 .00 block 15 lot 1 .006
Cross Street BRIDGE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• • „ •
OFFICE OF THE TOWN CLERK 'c�VFFD(,�
• Town of Southold 0�� _ Application No.
Judith T. Terry, Town Clerk zs .. t-'P`: : y
Town Hall, 53095 Main Road a PA- $10.00 - Residential /d..aa
P. O. Box 1179 ur3 ��' , ' i ; $25.00 - Non-Residential
Southold, New York 11971 ''`�
Telephone 1k9/ ��� '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0.60
DATE 10//x,
'OWNER NAME: AN` A0A17 S _ 496-076 '
•
OWNER MAILING ADDRESS: s,ro ��JEU1 EST Jr
6Akt)Eff ci7y n► .y
OWNER PROPERTY ADDRESS: AVOW/ A',d /oJou &Air
OWNER TELEPHONE NUMBER: G-<9 5(37 S-S)O
TAX MAP NO. : Section Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank i New Existing
• Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: 4/1:21 9 j)c E 1/4P)/"Ig/
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 natur of Applicant_
RECEIVED BY:
Town Clerk's Office
DATE:
I TOWN or SOu1IIOLD
I l irket No ic3 _ •
rintrrn,
_arra 0.
r ,v1S f lti-e, ,
Sc, it-A4
[� ..R WAS! E (i " yf `°Y
_—inc�R r o
l ��' ree• $ t)) per gallon
'nnni�
Maine of I tauter. . . /�/ ree, $ Y(:'---. ttaicl
. - •t•f Y'. . I/ —1_.I .e , . , . . . . . �-
Permit Number . . . . . . .( ,/ i Date ��/ -S'<) paidl
Y . . . . . . . . .
Southold Iown Clerk
Truck Capacity . . . . ? � c)
///���i, Gallons I.irluicl Waste
Date Pumped. .• C.�'
Residential . . • . ! • •/
. ` . . . .Commercial. . . .
I I Shl_I T LOAD n Restaurant. , �"
-----_Gallons
-
oration• /
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Name of Owner. .e. 4 --6-
i-i . , ... . . . . .
Street . . .13agh .017'457I,,., _ _
Telephone Number . . • • • • I lamlel. . . , or,2;, J e.
/• lax Mat /� !1
Cross Street. . dg--)17I Number ./1�-�� o /,
Dian,am (locating buildin . . . . . . . . . . . .
app,oxirnately.) g and cessttool. Give nvrlh arrow and feel of distance,
1
-4, L��� B, - .
i
i •.4
'0.05 .. 'Y
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I hereby certify that the above originated within the Town of Southold/Town of
Island at the above location(s), and to the best of my knowledge contains Shelter
ha7mdrnr§, or toxic wastes. raise statements made herein are punishable
dertteanor pursuant to Section 7.11745 of the Penal Law of 11 urns no as a In ig-
chemicals,
may result in my arrest and the impoundment of the vehicle I ams)drivofing. New York, and
Name utg.
of Driver . �;�hOn3r j( .
. 'Signature of Driver , 7 • . . . . . . . . . :2,7,1/
.Received bv.. . , .q.p . /. . . . .
.„
'Uate . . c ppp a Time .
•
111 Treatment Plant
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