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JUDITH T. TERRY < Town Hall, 53095 Main Road
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TOWN CLERK T • P O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �. � Fax (516) 765-1823
�® ��' Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1768-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ORISTANO, GEORGE AND DOLORES
Mailing Address 1 166-25 POWELLS COVE BLVD.
Mailing Address 2 APT. 10B
City St Zip WHITESTONE NY 11357-0000
Property Address 1 3620 NASSAU POINT ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 718-746-6964
Tax Map No. section 111 .00 block 4 lot 34.000
Cross Street OLD MENHADEN RD
Date Of Last Pump Out 0/00/00
Issue Date: 9/26/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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" OFFICE OF THE TOWN CLERK ,c���FO(�• `�
Town of Southold �� - CQ ' . Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road } $10.00 - Residential
P. O. Box 1179 cra Wit ' z $25.00 - Non-Residential
Southold, New York 11971 O ® °'-
Telephone j 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATEeda7 . *:'-
OWNER NAME: 6.7ea z 6 6JDJ i2 J t-sr#9y1/O
OWNER MAILING ADDRESS: /‘ aj ,,u,eJLs. Gote 1?1,�.0. Gos
Pil Tei-Pbsve-J Jt/ //36-7
OWNER PROPERTY ADDRESS: J�6 c /hlsS4.- Po ,Air 09O
$1//47e snwe 7, g 6 ^6 g'4671.
OWNER TELEPHONE NUMBER: i/,9ss pr 676, 73 ' 2fi7?
TAX MAP NO. : Section 11/ Block 47 /7 Lot , K
CROSS STREET: .®,C.47 4JL Ale Tel (e.01,P
TYPE OF SYSTEM: Septic Tank New Existing t�
Cesspool New Existing
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
,l Nc/k' of distance, approximately, to building and closest road.)
ar-
''Si ature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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