HomeMy WebLinkAboutMottola Town Hall, 53095 Main Road
�® O ��- P.O. Box 1179
�® °� Southold New York 11971
JUDITH T.TERRY
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�� ���� TELEPHONE(516)765-1801
TOWN CLERK
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. 1256-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MOTTOLA, PHILIP A.
Mailing Address 1 15 PARKWOOD COURT
Mailing Address 2
City St Zip ROCKVILLE CENTRE NY 11570-0000
Property Address 1 3265 PARK AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 000-766-9177
Tax Map No. section 123.00 block 8 lot 22.004
Cross Street BUNGALOW LANE
Date Of Last Pump Out 0/0Q/00
Issue Date: 9/28/89 Judith T. Terr
Southold Town Clerk
(TOWN SEAL)
• •.. .
OFFICE OF THE TOWN CLERK �SWFO(k�'-
Town of Southold - , ,-6" ' e& I. A lication No.
Judith T. Terry, Town Clerk • y pp
Town Hall, 53095 Main Road `':�r4 :'� I $10.00 - Residential
P. lex '.r�'y
O. Box 1179 tai �� ',.,�'F,,-t,� i $25.00 - Non-Residential
Southold, New York 11971 O ® '. '' - $
Telephone •®l •
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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.
Fee $ 0` .`71)
DATE /..\/2-(//6"
OWNER NAME: /()/) / // . // ' /V/ U d l l�, •
OWNER MAILING ADDRESS: /,S A-/-/CLQ o C.) 1_ Cc'
e() aCu ate Ctc. Ai(7 /( 5 76)
OWNER PROPERTY ADDRESS: ?L1 / c°_ r"ft '
OWNER TELEPHONE NUMBER: 7t6 f 77~(Z, U- C . w—r2 f ( ma, ? -
1 O
J TAX MAP NO. : Section Z"3 Block C� Y. Lot f 2 2- ' /y
CROSS STREET: Ar---fr /TO. @-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT:` p 6i
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.)
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CesseO L
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f:ii:,� 0erg-
y Aignature of Applicant
RECEIVED BY: Ai, ,, „____(-2 (;6_4___
• hCl rk's Office
DATE: SFR 28 M9
Tom Clerk Souttioff