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JUDITH T. TERRY < Town Hall, 53095 Main Road
TOWN CLERK ® ; P.O. Box 1179
t Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ��
�® ��" Fax (516) 765-1823
MARRIAGE OFFICER '
RECORDS MANAGEMENT OFFICER 's/®1 �-�' Telephone (516) 765 1801
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FREEDOM OF INFORMATION OFFICER �:� �rrr��
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3285-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CARUSO, VICTOR A.
Mailing Address 1 16 STUART STREET
Mailing Address 2
City St Zip WALDWICK NJ 071163-0000
Property Address 1 1500 BAYVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 201-444-3528
Tax Map No. section 52.00 block 5 lot 52.000
Cross Street COLONY ROAD
Issue Date: 11/30/911 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 90,
Town of Southold Oc3�FFO(�C'-
D ',1 Application No.��e�
Judith T. Terry, Town Clerk ;
Town Hall, 53095 Main Road a $10.00 - Residential 1/11
P. 0. Box 1179 to - ' $25.00 - Non-Residential
Southold, New York 11971 OJ' �••
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 44,14 L 4/ 17f
OWNER NAME: C rwri A CARu;0
OWNER MAILING ADDRESS: a $7?JARr S'%
WAL /eK1 0'7/44'3
OWNER PROPERTY ADDRESS: 4.4-A'04, i54y
5DorHHhA` L•4, H 16/ 77/___
OWNER TELEPHONE NUMBER: (zo/) H449-3(2-r
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TAX MAP NO. : Section 6�o2 Block Lot
CROSS STREET: CCh,O/1Y /?OAD
TYPE OF SYSTEM: Septic Tank / New Existing
Cesspool New Existing
Residential 1✓ 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.)
dY' ' 4 /1'41/''X' -._
Signatur of Applicant
RECEIVED BY: R
ECINVED
NOV I"ooi},9Ierk's Office
DATE: ion Clark
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