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. , JUDITH T.TERRY ;�'®�® �c Town Hall, 53095 Main Road
TOWN CLERK ` P.O. Box 1179
w= ® �� Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER y '�1 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER .` `1\ �i� Fax
(516) 765-1800
FREEDOM OF INFORMATION OFFICER —.. •��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3524-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner CANUSO, VICKY E.
Mailing Address 1 P. O. BOX 694
Mailing Address 2
City St Zip QUOGUE NY 11959-0000
Property Address 1 ROSEWOOD DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-653-9548
Tax Map No. section 113.00 block 2 lot 9.000
Cross Street COX NECK ROAD
Issue Date: 10/08/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFIG€ OF THE TOWN CLERK oc�\��F�(��'- -
Town of Southold , 0�� CQGy';, Application No. .��` �-f
Judith T. Terry, Town Clerk .
Town Hall, 53095 Main Road -� $10.00 - Residential
P. 0. Box 1179 cr3 - ;' $25.00 - Non-Residential
Southold, New York 11971 Oft 0*.$
1,
,, Telephone —
(516) '765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for,
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE c\\3b Cj Co
OWNER NAME: V Cc , �,�•nJ �,Sp
OWNER MAILING ADDRESS: ,O b1 cqy
_ OWNER -PROPERTY ADDRESS: Z5 S`Q,`3a�-� �1. 1�'��`� �` -
•
OWNER TELEPHONE NUMBER: 0053 Q 1
TAX MAP NO. : Section \ VS 0 7j 'J Block Lot I • 0 0 Z�
CROSS STREET: C_,b.-$.
TYPE OF SYSTEM: • Septic Tank • , New Existing
Cesspool New Existing
Residential Non-Residential
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.)
- 1 )\C‘
Si n ure of Applicant
RECEIVED 13Yr QQ�� EE n
�� TdJVfSC�C�er s Office, .
;
DATE: 0 CT 71996
SOuthOld TOwn Clerk - `