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Crjr 4��,,, Town Hall, 53095 Main Road
k = ,� P.O. Box 1179
``�KI :ES �® �� Southold, New York 11971 TELEPHONE.
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JUDITH T. TERRY
TOWN CLERK (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. 1049-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TOLOSA, MARIANO
Mailing Address 1 1385 DELMAR DRIVE, BOX 227F
Mailing Address 2
City St Zip LAUREL NY 11948-0000
Property Address 1 1385 DELMAR DRIVE
Property Address 2
City St Zip LAUREL NY 11948-0000
Owner Telephone No. 516-298-5097
Tax Map No. section 127.00 block 4 lot 11 .000
Cross Street JOSEPH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 3/15/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ��FD�,.'-
Town of Southold � G- Application No./d (
Judith T. Terry, Town Clerk .� r- i ,
Town Hall, 53095 Main Road `` ''`e`v" "'� Residential
P. O. Box 1179 u' f6:-
, i Non-Residential
Southold, New York 11971 O ® # ' $
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Telephone _ = j 0-1.9
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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. /oLff
/
Fee $
DATE 3—
OWNER NAME: / yjQ/7 / / at
OWNER MAILING ADDRESS: /S g'4' /17,7 4
b 9.A: x.2 7 F /1/y. 1 l q ?
OWNER PROPERTY ADDRESS: '
OWNER TELEPHONE NUMBER: •`zq$_ p _
TAX MAP NO. : Section 5 4 S' ' Block c Lot 'jd
CROSS STREET: •5'OO f %p Joss e 6- s7�€ e U --�o�` s,0.-,e
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing X
Residential x 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
if of distance, approximately, to building and closest road.)
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Town Clerk's Office
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