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JUDITH T.TERRY Town Hall,53095 Main Road
%TOWN CLERK , g % P.O.Box 1179
REGISTRAR OF VITAL STATISTICS Q 0 Southold,New York 11971
MARRIAGE OFFICER N.44 e/C�'�� Fax(516)765-1823
RECORDS MANAGEMENT OFFICER 04 `2 s' �ose. Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER .011
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3245-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner MORABITO, ROSE
Mailing Address 1 P. 0. BOX 1631
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 530 ROGERS ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3190
Tax Map No. section 66.00 block 2 lot 34.000
Cross Street HIPPADROME DRIVE
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Issue Date L0919#— Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'OFFICE OF THE TOWN CLERK •50Mir °--
Town
-Town of Southold % CQ4.+-1; Application No., ,./S--
Judith T. Terry, Town Clerk .� ''' .:-
Town Hall, 53095 Main Road -4 $10.00 - Residential
P. 0. Box 1179u-3 -2';'-, -, „:',It;.• hzi ;' $25.00 - Non-Residential
Southold, New York 11971 s O` 'I` 0*.$
Telephone -V./ Y+
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. S ... Si. "--S/'
Fee $/0;
DATE '9' /2"- /
OWNER NAME: 0 ,„ niD 2 .4 P,-ID
OWNER MAILING ADDRESS: P O • /r / 3-,
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OWNER PROPERTY ADDRESS : OSS a) O e.4-g ,' .7-,'
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OWNER TELEPHONE -NUMBER: -2 6 .-C-- 3 / 9V
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TAX MAP NO. : Section 4'%:' Block Lot
CROSS STREET: / //
94 , ° 111./ .211%
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
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.)
/,,.. --.37-e_..„-- / /17*,
Signature of Applicant
RECEIVED BY: / 11111
Town Cler 's Offi
DATE: 9/.. _,/
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