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JUDITH T.TERRY p0" Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ;® Fax Fax(516) 765-1823
MARRIAGE OFFICER �/� _47/
RECORDS MANAGEMENT OFFICER ®.( *Goo. Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICERNo ,.°��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3625-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner PERINI, DOMINICK AND WINIFRED
Mailing Address 1 P. O. BOX 1252
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 7213 GREAT PECONIC BAY BLVD.
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5042
Tax Map No. section 126.00 block 10 lot 1 .002
Cross Street BRAY AVENUE
Issue Date: 5/06/97 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
;OFFICE OF THE TOWN CLERK �c�' FUIL--'=
Town of Southold �% CQ Application No.
Judith T. Terry, Town Clerk �� f;```; '': �t:)
Town Hall, 53095 Main Road 1:1?•' ''4'';'-':;`';': t $10.00 - Residential V
P. O. Box 1179 , "• *M;;, .'.rM ; $25.00 - Non-Residential '
Southold, New York 11971 0.O4k••••'--...,1\9"..,'�0��1`
Telephone ( y►
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ (a,
DATE 24.--/..4.7 )/ 77 .7
OWNER NAME: .L 4/A//'f'.2T/2 / ,t//
OWNER MAILING ADDRESS: /- D(
/ )-
OWNER PROPERTY ADDRESS : ? --2.-L4 "---?--e-e-a.-.-e=
OWNER TELEPHONE NUMBER : L.17 4 - 2- S - Li-6 Sz
•
TAX MAP NO. : Section / oZ C Block ` 6 Lot I. -2
CROSS STREET:
A-
TYPE OF. ;SYSTEM: = Septic• `Tank- -`•' " - ._ New Existing
Cesspool New Existing X
Residential x 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.)
Signature of Applicant
RECEIVED BY: ,
lel-/ ---
To nc Clerk's Office s 1'° -
DATE: Cc < -- - - - - _ _ __ _ _.
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Ga 717