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JUDITH T. TERRY - Town Hall, 53095 Main Road
TOWN CLERK ' p T 1 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER yQ ®- ,�, Fax (516) 765-1823
--,y1 �1D Telephone (516) 765-1801
1111
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3094-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner NICOLINI, ANTHONY AND JANE
Mailing Address 1 57-10 224TH STREET
Mailing Address 2
City St Zip BAYSIDE NY 11364-0000
Property Address 1 855 EUGENES ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-4070
Tax Map No. section 97.00 block 2 lot 18.000
Cross Street ROUTE 25
Date Of Last Pump Out 0/00/00
Issue Date: 8/17/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
F
OFFICE OF THE TOWN CLERK uFFO(,Y '-
Town of Southold � C'Q ' Application No.30-
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road , "r ""•; e. '� 1 $10.00 - Residential 1/
P. O. Box 1179cn `
$25.00 - Non-Residential
Southold, New York 11971 O �`
Telephone 0.(-• AA
�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ O
DATE Bll3425
OWNER NAME: IA (,1b#4 4 10eF e-61,4
OWNER MAILING ADDRESS: 5 7 0 �c� "it
OWNER PROPERTY ADDRESS: 0 CJ�.4
OWNER TELEPHONE NUMBER: 7,3i/ - VO 7D
TAX MAP NO. : Section Q7 Block 4 Lot /
CROSS STREET:•
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing a/
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Signatu e o pplicant
RECEIVED 'BY:11.-
Town lerk's Office
DATE: