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JUDITH T.TERRY � �„i0 skoot,t
yet Town Hall, 53095 Main Road
TOWN CLERK y P.O. Box 1179
w ” 7 Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER y� ®��� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER ®1 1° °. Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER ,•1
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3395-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PELLEGRINI, ROBERT AND RITA
Mailing Address 1 4.515 STILLWATER AVENUE
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 4515 STILLWATER AVENUE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-6346
Tax Map No. section 137.00 block 3 lot 4.000
Cross Street TRACK AVENUE
Issue Date: 10/12/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
I-1 /I •..
OFFICE OF THE TOWN CLERK �c,�IFOUI- ,- /�
Town of Southold �� 1.4---.\ Application No3-396—j
Judith T. Terry, Town Clerk �� ..
�% $1U.00 - Residential X
Town Hall, 53095 Main Road ..
P. O. Box 1179 u' ;� $25.00 - Non-Residential
Southold, New York 11971 0. '`' . *.$
.
.Telephone0.( * I� 'i
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
RECEIVED APPLICATION
OCT 1 2 1995 for
down Clerk Southold
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /a e
DATE 0-C4i— cy O"
OWNER NAME: 6c4' t _ ) f3_1111--in
OWNER MAILING ADDRESS: 2-1-5/j 5 'f(/Edi' F(ICC ,
c :-1- 0toP) 1y /193e
OWNER PROPERTY ADDRESS: d'YI.C'� d
cJa
OWNER TELEPHONE NUMBER: 1-701- —63/46
TAX MAP NO. : Section I 3 7 Block 3 Lot q
CROSS STREET:
TYPE OF SYSTEM: Septic Tank V New ExistingV
p
Cesspool ✓ New Existing V
Residential V 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.
A' 'Sig ture of Appii = t
RECEIVED BY: ,, _At. �,a
own e(erk's Office
ME®
DATE: '
OCT 121W5
down Cleric SoutholL
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