HomeMy WebLinkAboutSirianni 1
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111 ®� ��,`
v :' Town Hall, 53095 Main Road
P.O. Box 1179
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iI Southold, New York 11971
VA' �2,
JUDITH T.TERRY "��.�,„r�<�' 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. 1295-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SIRIANNI, THOMAS W.
Mailing Address 1 P. O. BOX 836
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4005 OLE JULE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5420
Tax Map No. section 122.00 block 5 lot 24.000
Cross Street KRAUS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 11/06/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
Im
1, , ion i� _
OFFICE OF THE TOWN CLERK c0Fo(,� _ /��5,
Town of Southold 'V„.4--r4---N.,,,_o � • Application No.
Judith T. Terry, Town Clerk *:;:ii a'+ _,
Town Hall, 53095 Main Road ``' ''4. "4 ' $10.00 - Residential
P. O. Box 1179 ` 3,61.=V
� ,,�, ,, % $25.00 - Non-Residential
Southold, New York 11971 O � '4*-? .�`�
Telephone . 01 Or/
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
ror-
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 0a2,/3
Fee $ •
DATE I-e7
OWNER NAME: 4:• '
OWNER MAILING ADDRESS: Po /ix
Ei-
"677-7/7-6y_-4 / '2
OWNER PROPERTY ADDRESS: �{-{-C-0 S-�(-6, , 1 cie;
OWNER TELEPHONE NUMBER: 0- C-�9-0
TAX MAP NO. : Section S a Block Lot
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
_ Cesspool l,/ New Existing
Residential 1/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: YVeFie9
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.)
S gnature of A lican
g pP
RECEIVED BY:
R gE�,wn Clerk's Office
DATE: NOV 0619 ,1
Tom Clerk Scow
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