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JUDITH T. TERRY , Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1179
REGISTRAR OF VITAL STATISTICS .�` Southold, New York 11971
MARRIAGE OFFICER �® Q ''1 Fax (516) 765-1823
= � ��;® �! Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1908-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PUGLIESE, PATRICIA AND RALPH
Mailing Address 1 P. O. BOX 467
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 2705 BRIDGE LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5983
Tax Map No. section 85.00 block ---2 lot 1 .00a l
Cross Street NORTH ROAD/ROUTE 25
Date Of Last Pump Out 0/00/90
Issue Date: 5/22/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �COFOur,=
Town of Southold �% - CQG Application No. ( �j D g"
Judith T. Terry, Town Clerk ` �00'w Y y
Town Hall, 53095 Main Road a Zi. `'- ` ;r $10.00 - Residential /..----
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p. O. Box 1179 cn ".- ���t; -‘ $25.00 - Non-Residential
Southold, New York 11971 0 �-'tif-."f s�`
Telephone oj 11 1
(516) 765-1801
' TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
- - :or
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /9O 3
Fee $ /a --
DATE c\fi),1 1,, 27-) ) 9 cl7.�"
OWNER NAME: El a Rni--Pit P
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OWNER MAILING ADDRESS: O. hq)( 469
OWNER -PROPERTY ADDRESS: Z(10.-&-• ib \bf� y-6---
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OWNER TELEPHONE NUMBER: Yji- 5103
TAX MAP NO. : Section GIBS— Block 007_ Lot 00l
CROSS STREET: �'(Z�� 9Q�� �(1� ' -\-- rIS�
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool J , New Existing V/
Residential / Non-Residential o
DATE OF PREVIOUS PUMP-OUT: ,��i '',\ * 0 ` 11 / 9 < .J
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.)
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Signatur f Applicant
RECEIVED BY: / t'll't
Town Clerk's Office
DATE: 5 cA ( C/