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,,i Town Hall, 53095 Main Road
"' .ti, P.O. Box 1179
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. Southold, New York 11971
JUDITH T.TERRY 'S FAX(516)765-1823
"����� 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. 1524-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PROFERA, LOUIS J.
Mailing Address 1 1351 MERRICK AVENUE
Mailing Address 2
City St Zip MERRICK NY 11566-0000
Property Address 1 40 OSSEO AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-868-4200
Tax Map No. section 87.00 block 3 lot 19.000
Cross Street MINNEHAHA BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 8/31/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �cl\VFU - - etz
Town of Southold b �� LQG� Application No.
Judith T. Terry, Town Clerk _
Town Hall, 53095 Main Road :� 7 $10.00 Residential
P. O. Box 1179 cry ` �y � * ` $25.00 - Non-Residential
Southold, New York 11971 O "°:= �`�
Telephone0.( .
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/o '
DATE .„207 /99a
'OWNER NAME: .few/ _r ® / ye f to ' •
OWNER MAILING ADDRESS: /35/, /: ,9l✓e
M/ //-5-(6"
OWNER -PROPERTY ADDRESS,: , T, !t eei
LI:!?/7/X- i V//7
OWNER TELEPHONE NUMBER: f! 6(`_ T2 d e
TAX MAP NO. : Section ®�y Block '3 Lot Lot /
CROSS STREET: 79//)i7 eja_1, ,g//d_
TYPE ;OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential -
DATE OF PREVIOUS PUMP-OUT: cSX61.40
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.) .
•
Sign ofAp�licant
RECEIVED- BY: . - _ . . - - -RaVe
Alerk s Office
DATE: AUG 31 1990 -
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