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JUDITH T. TERRY ;z.) Town Hall, 53095 Main Road
TOWN CLERK ; ` M P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS n Southold, New York 11971
MARRIAGE OFFICER -� Fax (516) 765-1823
^" r 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. 1592-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Tir
Name Of Owner TAN ,GLIA, JOHN
Mailing Address 1 7260 HORTON LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 7260 HORTON LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2875
Tax Map No. section 54.00 block 3 lot 11 .000
Cross Street SOUNDVIEW AVENUE
Date Of Last Pump Out 0/00/00
46111.4.
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •c,�FFO(,-
Town of Southold Q C'0 '- Application No. ` 5Q`�
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -"'{_;. ;: <�1 $10.00 Residential
p. O. Box 1179 cn $25.00 - Non-Residential
Southold, New York 11971 O 3,"'` ;= ��`�
Telephone *Oj s�� ���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLI CAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
'OWNER NAME: J0,- -337.---e7794/? •
•
OWNER MAILING ADDRESS: 7 ao /4‘,73.A.1 6410--
OWNER PROPERTY ADDRESS: - S 0" /Ord v"
OWNER TELEPHONE NUMBER: 76 % 2f7r
TAX MAP NO. : Section J7/ Block 2 Lot 7/
CROSS STREET: i/20-� dI*74-14.10—
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool I./ !�
New Existing
Residential !// Non-Residential
DATE OF PREVIOUS PUMP-OUT: .4/.0
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 A.�'icant
RECEIVED BY: 31,
Town Clerk's fice
DATE:
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