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JUDITH T. TERRY ; Town Hall, 53095 Main Road
TOWN CLERK Act P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS �� Southold, New York 11971
MARRIAGE OFFICER yQ ��' � Fax (516) 765-1823
WO L /tV i'�� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2028-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CARDINALE, ALAN
Mailing Address 1 P. O. BOX 77
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 4455 OREGON ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-298-11223
Tax Map No. section 94.00 block 3 lot 4.001
Cross Street ALVAHS LANE
Date Of Last Pump Out 0/00/00
Issue Date: 12/23/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE` OF THE TOWN CLERK cOFO(K ^�0�o/
Town of Southold �� -rVQG Application No.
JudithT. Terry, J0Wn Clerk ) _ '
Town Hall, 53095 ainRoad $10.00 - Residential
p. O. Box 1179 $25.00 - Non-Residential
New York 11971
Southold,
Telephone 5 ?t' 4 �OI
(516) 765-1301 ,
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. -
Fee $ 1 ® .-07)
DATE lt=11(4q�
OWNER NAME:
OWNER MAILING ADDRESS: � g6-kL ? 7
Ch u- /A - 4 / / 9 S D
OWNER PROPERTY- ADDRESS: 4140-75- ciAtgr>„)
( fq3 -
OWNER TELEPHONE NUMBER: 9e - ?_ge— Pc-749'ce
TAX MAP NO. : Section ; Block 3 Lot A l
CROSS- STREET:
TYPE, OF SYSTEM: -'Se'ptic-°Tank __'_____ -. _._ New Existing
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
of distance, approximately, to building and closest road.)
,-;;;;W-
gnature of Applicant
•
RECEIVED BY: --
• Town- Clerk's Office - =
•
DATE:'