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JUDITH T.TERRY ��/�� � Town Hall, 53095 Main Road
TOWN CLERK ,� P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
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MARRIAGE OFFICER `4. 4, * ��: Fax(516) 765-1823
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RECORDS MANAGEMENT OFFICER ®°� d� Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER �... .�'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3714-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner PELLICANO, RUSSELL A.
Mailing Address 1 359 PENNSYLVANIA AVENUE
Mailing Address 2
City St Zip BAYSHORE NY 11906-0000
Property Address 1 9680 NORTH BAYVIEW ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-666-8318
Tax Map No. section 79.00 block 8 lot 13.001
Cross Street SEAWOOD
Issue Date: 10/30/97 Judith T. Terry
Southold Town Clerk
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(TOWN SEAL)
5 3 7/�
OFFICE OF THE TOWN CLERK �FFU �-
Town of Southold Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road $10.00 - Residential
P. 0. Box 1179 s.. ►
� ,•. � $25.00 - Non-Residential
Southold, New York 11971 OO �0 ��`
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 6c-7 30 (757
OWNER NAME: 12,asel I
OWNER MAILING ADDRESS: 35 7 klievsre
?4 sl-f '- O( « 706
OWNER PROPERTY ADDRESS : r( 6o 14, 3Ati ✓'ce i
50L;z/o-L-a /(77/,.
OWNER TELEPHONE NUMBER: C66- 6. 3/e
TAX MAP NO. : Section '7' Block i`3 Lot /3 t
CROSS STREET:
TYPE OF SYSTEM: Septic Tank `� New Existing
Cesspool New Existing
Residential f Non-Residential
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.)
i
Signature of Applicant
RECEIVED BY:
Town Cleric's Office
RECEIVED
DATE:
O CT w ® 1997
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