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LP .w , Town Hall, 53095 Main Road
=_`o'® ®�-�.� P.O. Box 1179
---A1 f°,:, Southold, New York 11971
JUDITH T.TERRY �I� '��/�� �i FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1473-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CIACIA, ANNA
Mailing Address 1 D'AUGUSTA, MARYANN B.
Mailing Address 2 55 MAIN ROAD
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 55 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-477-1696
Tax Map No. section 53.00 block 2 lot 20.000
Cross Street KERWIN BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 5/30/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK • i' Fu; .,� •
Town of Southold � _. `C'�G= Application No. /tjf3
Judith T. Terry, Town Clerk �' y
Town Hall, 53095 Main Road $10.00 - Residential
P. 0. Box 11
- 44— $25.00 - Non-Residential
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Southold, New York 11971 c:::,
0�'•S
Telephone io.( , NP
(516) 765-1801 -
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0 177..)
DATE .- 'a.S *
OWNER NAME:4/ Atf C/fl Cn I'M y4AiA/ iQ Cc%ryc,'J bY9 i/60_577÷ •
OWNER
6L) _/'-
OWNER MAILING ADDRESS: 3c/7,4/A/ i L
A17 11777
OWNER PROPERTY ADDRESS: jJia/Y'YLL../
• OWNER TELEPHONE NUMBER: 4/77 ,- /6 9n
TAX MAP NO. : Section cl3 Block Lot 070
CROSS STREET: KC/e.4.11n./ QLvzi yLpf7 r..0,11
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
JJ
Residential L" Non-Residential
DATE OF PREVIOUS PUMP-OUT: Her
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.)
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Signature of Applicant
/C 4
RECEIVED BY:
Town Clerk's Office
DATE:
P/0 LOT 177 AREA = 458 8 .50 FT
Q h1 -TOTAL AREA 10938 SO F7 �� t �`
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���.:,,/2r e TOWN OF SOUTHOLD
SRO 'e„ v SUFFOLK COUNTY , N. Y.
SO, h
1000 - 053 - 02 - 20
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�; SCALE I 30'
I f'AY 4 , 1887
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SCHLOL DISTRICT -
G=EENT
E FIRE DISTRICT - 31
E 1 4\t CERTIFIED TO
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C/°, '? :\:: SOUTNOLD S•".V;NGS BANK
:( o- IA,?, ?,, �? .� )_ 1 PECONIC :.BST.'.•AC71NC
'',`/rf :k - •-_r GUIDO CIACIA
,,, "'✓ / 'fYd"^- N Y S LIC NC 45619 , - ^- NNA CIACIA
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r5I6 ), 765 - 5020,S 5 ENGINEERS ,P C . r.r_:-c :1a:"L,d
E„� NUPO 6E.S REFER TO 'nwENCEC POsc 'L' Or PELONIC
( 516 ) 765 5020 i .j6C—"9^ ELY ESTATES' FIL EC POLY IS, '533 IN THE OFFICE
P 0 BOX 909 _ OF THE 5.' O_K CC-v.7Y CLER r As 14 NC 1124
£ D _s DF w,C KMnw FLiK LATS F.:EO SE=' 28,1527
MAIN ROAD at
SOUTHOLD, r: Y 11971
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