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JUDITH T. TERRY �� Town Hall, 53095 Main Road
TOWN CLERK g i P.O. Box 1179
REGISTRAR OF VITAL STATISTICS vtr2 T '� Southold, New York 11971
MARRIAGE OFFICER Fax (516) 765 1823
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Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1651-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SPIRO, ALFRED
Mailing Address 1 42 PADDINGTON ROAD
Mailing Address 2
City St Zip SCARSDALE NY 10583-0000
Property Address 1 340 GLENWOOD ROAD
Property Address 2
- City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5873
Tax Map No. section 110.00 block 6 lot 5.000
Cross Street HAMILTON AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
IIS
OFFICE OF,,, THE TOWN CLERK S.
Tcwn of Southold Q� r �C� Application No. / U
,,'`
Judith ,1*. Terry, Town Clerk
Town Hall, 53095 Main Road �, $10.00 - Residential
p, O. Box 1179 Cr3� ,,:;�;� ��� $25.00 - Non-Residential
Southold, New York 11971 O ® ?°'•:0���`
Telephone ®j � • '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0
DATE ,e3/Zpict
OWNER NAME: 4)I-Ce. D •
OWNER MAILING ADDRESS: �g cAS( VU - oyc-K0
S olC5.8° 1 y. , ►esg3
OWNER PROPERTY ADDRESS: 3'f O 6-1-entt Q�
l ,od7\nCX, ye /J y , J/q3 5
OWNER TELEPHONE NUMBER: 5m - 7311 -5g7; / 9/4'-las -194'4
TAX MAP NO. : Section 110 Block 6 / Lot .5
CROSS STREET: 14avn; 1--,-,' Ave. ,
TYPE OF SYSTEM: Septic, Tank New Existing
Cesspool v New Existing v7
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: . - QQI
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.)
Signature of A plicant
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RECEIVED BY:
(ow Jerk's Office
DATE: /0-0 79/
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