HomeMy WebLinkAboutMoisa OFFICE OF THE TOWN CLERKFO
Town of Southold Q��FC�
Judith T. Terry, Town Clerk •
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Town Hall, 53095 Main Road
P. 0. Box 1179csa
Southold, New York 11971 p ® �- ••
Telephone ^�®1 Is •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 393 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Edward Moisa
OWNER MAILING ADDRESS: Ruth Road
Mattituck, New York 11952
OWNER PROPERTY ADDRESS: Ruth Road
Mattituck, New York
OWNER TELEPHONE NUMBER: 516-298-8809
TAX MAP NO. : Section 106 Block 7 Lot 13
CROSS STREET: Zena Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: March 21, 1987
Judith T. Terr4
Southold Town Clerk
DATE: August 11, 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK CO HU( --
Town
Town of Southold Deo , �Q Application No.
Judith T. Terry, Town Clerk %-‘‘
ti
Town Hall, 53095 Main Road ' :' Residential
P. O. Box 1179 cn , p. Non-Residential
Southold, New York 119710 ,t-t;tO�i'�,`
Telephone 5 .�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/O
DATE
OWNER NAME: 411,,u_o,a,
OWNER MAILING ADDRESS: PA,v""' , C ' C i 7.
OWNER PROPERTY ADDRESS: )Qin Jed_ yrfr ,7�
OWNER TELEPHONE NUMBER: ��f _ 8'801
TAX MAP NO. : Section ® (a Block 7 _ Lot
CROSS STREET: cam „
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing
residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: GA . a /� 1177
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.)
Signa ure of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: //. /2?7
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