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�\ ^r” :`r Town Hall, 53095 Main Road
. ', Z:•• P.O. Box 1179
_ ®n ���� Southold, New York 11971
JUDITH T.TERRY ='�iiowileo �I 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. 1155-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner PUPILLO, LORENZO AND ROSE ANN
Mailing Address 1 175 PARK AVENUE
Mailing Address 2
City St Zip DEER PARK NY 11729-0000
Property Address 1 8 SHORE DRIVE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-586-3568
Tax Map No. section 47.00 block 2 lot 23.000
Cross Street WALTER AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 6/15/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK j�FF�(�,,,
Town of Southold Q F.. e� - Application No. 7,
Judith T. Terry, Town Clerk . i34
Town Hall, 53095 Main Road $10.00 - Residential
P. O. Box 1179 cn f4 x �,,1
� '�,;,. $25.00 - Non-Residential
Southold, New York 11971 O ® $
Telephone -TQ( •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10'.00
DATE 6/11/8q
'OWNER NAME: LORENZO AND ROSE ANN PUPILLO
OWNER MAILING ADDRESS: 175 PARK AVENUE, DEER PARK, N.Y. 11729
OWNER PROPERTY ADDRESS: 8_ Shore Drive, Greenport, N.Y. 11944
OWNER TELEPHONE NUMBER: (516) 586-3568
TAX MAP NO. : Section Block Lot
CROSS STREET: NO CROSS STREET PRIVATE ROAD - OFF SILVERMERE
TYPE OF SYSTEM: Septic Tank New Existing '
Cesspool XXXX New Existing XXX
Residential Non-Residential
XXXX
DATE OF PREVIOUS PUMP-OUT: 6/88
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to buiiding and closest road.)
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Signature ofplicant
RECEIVED BY:
Town Clerk's Office
DATE:
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