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JUDITH T. TERRY • ; ` : Town Hall, 53095 Main Road
TOWN CLERK C=1
T P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
Fax (516) 765-1823
MARRIAGE OFFICER O 0� •
$v • 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. 3116-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner SPITALIERE, JOSEPH C.
Mailing Address 1 9 NOEL PLACE
Mailing Address 2
City St Zip SMITHTOWN NY 11787-0000
Property Address 1 950 ORCHARD LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 90.00 block 4 lot 14.000
Cross Street CEDAR BEACH DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
�►� •
OFFICE OF THE TOWN CLERK �FFU�
Town of Southold ��S CQ Application No. _3/4
Judith T. Terry, Town Clerk • 1,7 .4%,
Town Hall, 53095 Main Road _ $10.00 - Residential
o �
P. O. Box 1179 cr3 $25.00 - Non-Residential
Southold, New York 11971 O*0-1111: '' '�`
Telephone 'i •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE e7Ark 3
OWNER NAME:
OWNER MAILING ADDRESS: qj R.-
S )7A4o4 � �% . //7 8 7
OWNER PROPERTY ADDRESS: gra,
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section Block 7 Lot
CROSS STREET: e•edaa, Beer. l _
•
TYPE OF SYSTEM: Septic Tank P/ New Existing
Cesspool New Existing
Residential -1,/ Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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 anri closest road_)
'.np ure of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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