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r, Town Hall, 53095 Main Road
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T` f �� P.O. Box 1179
�„ Southold, New York 11971
JUDITH T.TERRY ®�, pi_ 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. 1175-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New iNc Existing
Name Of Owner QUINTIERI, EDWARD
Mailing Address 1 290 SUMMIT AVENUE
Mailing Address 2
City St Zip MOUNT VERNON NY 10552-0000
Property Address 1 PECONIC BAY BOULEVARD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 914-667-5486
Tax Map No. section 126.00 block 6 lot 1 .000
Cross Street SIGSBEE ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 6/27/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 4`��\FFQ( r _
Town of Southold Oho , CQG', Application No.
Judith T. Terry, Town Clerk ZP
Town Hall, 53095 Main Road `. Residential
O p .
P. O. Box 1179 cn ' �; �� '�� Non-Residential
Southold, New York 11971 O ® 2 s' �••l
Telephone 4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for .,
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 1c-)-M
DATE 'Zb '6C-)
OWNER NAME: BbA;TAQb CCS i 1..,11.k 957--)
OWNER MAILING ADDRESS: -C611) SUrnvtf r A U?.,
4rnt)tiLri v 61- 1 -1k1 10SS'?
OWNER PROPERTY ADDRESS: �10.,'S a - ),-3/1! %ALI IU,L)1),
.m ft 11 lie,
OWNER TELEPHONE NUMBER: ,61L.j (A,-25 141:,b
TAX MAP NO. : Section �,t Block 47 Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
i Cesspool f New 1 Existing
Residential '7f Non-Residential
DATE OF PREVIOUS PUMP-OUT: 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.)
Signatu a of Applicant
RECEIVED BY:
Town Clerk's Office
Mang
DATE:
I SUFFOLK CO. HEALTH DEPT. APPROVAL
't j
•
_ i i I •, , v r -- STATEMENT OF INTENT �1
s �'"''' ) ? r ! i THE WATER SUPPLY AND SEWAGE DISPOSAL
.,,
= i
I ~' SYSTEMS FOR THIS RESIDENCE WILL
o 1-6.• 0, Ls,„. _ J , r CONFORM TO E STANDARDS OF THE
III
-v' "'� o I - ._� a SUFFO oma. ► HEAI�LH SERVICES.
o .- i t 1 (S) —
ro g 2 F ; :— ___�_ ` _ _ 1 ' t {a ! APPLICANT
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FE, t= I I 17
CC' `: 6coc�`. = {{ �� ff SUFFOLK COUNTY DEPT. OF HEALTH
SERVICES — FOR APPROVAL OF
- o '� CONSTRUCTION ONLY
F.,_ -CM:2-- :r.• DATE:
,g 4- v �; 5 ( J`', I-7:- :. , l _ �,. i':%' ' l' '_'-,'' ; ) �" / H. S. REF. NO.:_ 8 S Q �' -418
V. 3 . r" 0 1 1/; APPROVED:
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r-- — — - — — - 1 t SUFFOLK CO. TAX MAP DESIGNATION:
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{I q , {7 t71' OWNERS ADDRESS:
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' LICENSEDLAND SURVEY RS ..`I� ',''_'x`-''`''`10-'
, - "II • 1 GREENPORT NEW YORK
TEIJDYNE POST N81379