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JUDITH T. TERRA' ' , Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER ® /'�. Fax (516) 765-1823
‘- 4i, ,$,\.!;› �! Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1962-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KAPPA, DOM I N I CK
Mailing Address 1 1300 FLEETWOOD ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1300 FLEETWOOD ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7610
Tax Map No. section 137.00 block 5 lot 9.000
Cross Street BETTS STREET
Date Of Last Pump Out 0/00/00
Issue Date: 8/26/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
y I III
,OFFICE OF THE TOWN CLERK COFDCA- II
Town of Southold A CQ ' , Application
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road :'� ` $10.00 - Residential
P. O. Box 1179 u' %::, $`' ' 7 tri ` $25.00 - Non-Residential
Southold, New York 11971y®l`
Telephone ®j
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE S 02 /._ q2
OWNER NAM : i 0M inlcf - RaPPC4'
OWNER MAILING ADDRESS: J 3(20 J
1 / 93r
OWNER PROPERTY ADDRESS: 43 -
OWNER TELEPHONE NUMBER: c7 31/ v7'/C)
TAX MAP NO. tion J 3 7 Block ® C Lot 0 0 CI
CROSS STREET: E
Z-1-6,fro-
TYPE. OF 'SYSTEM:' Septic Tank / New Existing v
Cesspool ' New Existing
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT:`Z /cfc/2—
LOCATION MAP: Must be attached hereto fore permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road_)
IS
Signature Applicant
_ -
RECEIV'ED:. BY:-
Town Clerk's Office
DATE: "
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. .. ....,- '•-;.' ' ' '•••"-•)•-...' - , s : CERTIFIED..:- i=3:TOi',:'..-
'-irARINE-:-Milk AND:-'.BANK NA
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pcomic -ABSTRACT INC .
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' . DOM,I'NIC J. RAF'PA '
'
MAUREEN RAPPA
- . TITLE-NO . 605 - S - 65 33
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