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,• Town Hall, 53095 Main Road
+ P.O. Box 1179
d r ,r'� Southold, New York 11971
JUDITH T.TERRY ..,,,iii/' 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. 1559-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MORENO, CONSTANCE
Mailing Address 1 990 SIGSBEE ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 990 SIGSBEE ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-1132
Tax Map No. section 144.00 block 1 lot 1 .000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 10/23/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •
OFF.iC OF THE TOWN CLERK �c3VFFU �'-
Town of Southold � `'0�-_ Application No., 557
Judith T. Terry, Town Clerk . , a' w� _
Town Hall, 53095 Main Road r_<-� Y :'�`� $10.00 Residential
P. O. Box 1179 cry ��t - h�i ; $25.00 - Non-Residential
Southold, New York 11971 Off,
4 .
Telephone lei %it
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
. - OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 1? /-4-l?
'OWNER NAME: CO ,1/4),S7- C.C.C- 1`°I ON o •
OWNER MAILING ADDRESS: q o'D sic-5 6 ee-
M 4-Tr-( 1 'C!,€1C,. i) y . (c/(z
OWNER PROPERTY ADDRESS: Sot-Pie
OWNER TELEPHONE NUMBER: alit
TAX MAP NO. : Section / Block 1' Lot
CROSS STREET: i , Z;
TYPE OF SYSTEM: Septic Tank - New Existing
Cesspool New Existing
Residential -? Non-Residential
DATE OF PREVIOUS PUMP-OUT: �lyJ
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 Applicant
RECEIVED BY:
mown Clerk's Office
DATE:
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