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5 Town Hall, 53095 Main Road
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P.O. Box 1179
0.- Southold, New York 11971
JUDITH T.TERRY ----,,,,,../.41 FAX(516)765-1823
TOWN CLERK TELEPHONE(516)765-1801
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. 1509-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PUMILLO, JODY
Mailing Address 1 MAIN ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 MAIN ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5932
Tax Map No. section 143.00 block 3 lot 33.003
Cross Street MARLENE LANE
Date Of Last Pump Out 0/00/00
Issue Date: 7/31/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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"OFFICE OF THE TOWN CLERK �5\WF0(.,'��-
Town of Southold 0�% , CQG'; Application No. / ��'
Judith T. Terry, Town Clerk . �, `
Town Hall, 53095 Main Road ~ i'' ' Y ` Residential I/
P. O. ..Box 1179 cn -. l 3 ' Non-Residential
Southold, New York 11971 l'® � `�
Telephone =le/ 44•''-.''N.#'
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--("5°16) 765-1801 '
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
' APPLICATION
for _ -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. ` •
Fee $ ID. s°
DATE 9—dl.-47
OWNER NAME: ___\ 6CA Y
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iT
OWNER MAILING ADDRESS: ,, �J�, ` q � �;,�'
er
OWNER PROPERTY ADDRESS: J
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OWNER TELEPHONE NUMBER:
01' 7 5-95D--
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TAX MAP NO. : Section iy ; Block 3 Lot /
CROSS STREET: ®' '1 LEPL I 491Ik T
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing V
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1W
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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- Sig `;tur- of Applicant
RECEIVED BY:
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19 Town Clerk's Office`
DATE: -717;00 -
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