HomeMy WebLinkAboutSimeoni % Town Hall, 53095 Main Road
(07, fir " P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY
= i40,1-ill 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. 1442-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIMEONI, JOHN
Mailing Address 1 BOX 334
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 JOCKEY CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3292
Tax Map No. section 70.00 block 5 lot 10.000
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III •
OFFICE OF THE TOWN CLERK �S�FFo(k�„-
Town of Southold �Q ,fix-- -14-- Application No. /L/4/
Judith T. Terry, Town Clerk . -
Town Hall, 53095 Main Road 0 . �^, :� $10.00 - Residential
P. 0. Box 117`9' ala t,f a y�
.� � ., .� ,�� �% $25.00 - Non-Residential
Southold, New York 11971 - • O '® %O��`
Telephone .Q( .I
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION .
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / 6, Q d
DATE , / 5r
OWNER NAME: 9- �
OWNER MAILIN ADDRESS: 4j67" ,3..... 7
OWNER PROPERTY ADDRESS: et,c-/ < ( d t 2 .
v%! r cr f/
a 97 /
OWNER TELEPHONE NUMBER: ,c-i6 — 2‘6----- 3J-9.2--
,
TAX MAP NO. : Section 75--n, Block 5- ---/O
Lot
CROSS STREET: Mav-1J ,Pa,
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool New Existing V
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: e•--1.�cr-7-1-0----
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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Signatu a of Applicant
RECEIVED B
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fird cierk'�ffice
DATE: ® C
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