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`T9 � Town Hall, 53095 Main Road
-- ,� � P.O. Box 1179
4 `A�o l� Southold, New York 11971
JUDITH T. TERRY ������/01°VIII TELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1084-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner VITELIS, JOHN
Mailing Address 1 147-21 HOOVER AVENUE
Mailing Address 2
City St Zip JAMAICA NY 11435-0000
Property Address 1 345 WILD CHERRY WAY
Property Address 2 ARSHAMOMAQUE
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 000-000-0000
Tax Map No. section 52.00 block 3 lot 32.000
Cross Street BAYBERRY LANE
Date Of Last Pump Out 0/00/00
Issue Date: 4/18/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK F • '
Town of Southold A��� � �u'CO
, ,: Application No.'/(�
Judith T. Terry, Town Clerk . A 4
Town Hall, 53095 Main Road a �. ' Residential
P. O. Box 1179v' ` rw :;r<:.' Non-Residential
Southold, New York 11971 Qom a_; � '���
TelephoneQ( �.a� '�
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
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for
OPERATION PERMIT
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SEPTIC TANK or CESSPOOL
Operation Permit No. 2- �'O
Fee $
DATE 17-/7-
OWNER
V /7-OWNER NAME: .JOh,v Vito L/ S
OWNER MAILING ADDRESS: 'V7- 2/ Hop Ve,. 4 V e ivU e
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OWNER PROPERTY ADDRESS: 3f5- (Al(Lcafe
Rly W/ A I9AMoYDgG'
OWNER TELEPHONE NUMBER: -17')/
TAX MAP NO. : Section c2 Block ' Lot 32 •
CROSS STREET: 51<peRAV 4.7.1/Ve
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing,
Residential i2 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.)
Sign r of Applicant
RECEIVED BY: ` W�J� •
own Clerk's Office
DATE: �'J ( Y1
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