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ui Town Hall, 53095 Main Road
V. O � � P.O. Box 1179
x,424® o" Southold, New York 11971
JUDITH T.TERRY rte ���, 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. 1420-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MITAROTONDO, ANTHONY AND CAROL
Mailing Address 1 950 LITTLE PECONIC BAY ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 950 LITTLE PECONIC BAY ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-7436
Tax Map No. section 111 .00 block 14 lot 15.000
Cross Street HAYWATERS ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 3/16/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK o�FF��
Town of Southold Q CO - Application No.
Judith T. Terry, Town Clerk f Al 4y
Town Hall, 53095 Main Road �' $10.00 - Residential
to y
P. O. Box 1179 4 '� f� $25.00 - Non-Residential
Southold, New York 11971 Obi®a' "
Telephone Q( 1"
•
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 6.,C9 ()
OWNER NAME: ilAinhAiui `- -G 9U H (r ytw
OWNERoo
MAILING ADDRESS: qç0 44-K Pec'onv 62,7
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: ] 3 (o
TAX MAP NO. : Section 11 � Block itid Lot
lc
• CROSS STREET: P-AAP,014-MT5
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool (/ New Existing V
. Residential IV Non-Residential
DATE OF PREVIOUS PUMP-OUT: • • /, C . � Cr?
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.)
0 4 �L� �9
Si• . re of�"Appli ant
•
RECEIVED BY:
Town Clerk's Office
DATE:
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