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JUDITH T. TERRY ` Town Hall, 53095 Main Road
TOWN CLERK •
: ® r= • P.O. Box 1179
Lin P.O.
New York 11971
REGISTRAR OF VITAL STATISTICS = sY
MARRIAGE OFFICER ®,` ®� •�, Fax ne(5 (516)765-15-1
RECORDS MANAGEMENT OFFICER '7®1 �� Telephone 765 1801
FREEDOM OF INFORMATION OFFICER -4"'",00,01#0 1'°
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3195-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner CIAMARICONE, JOSEPH
Mailing Address 1 P. O. BOX 1631
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 585 PACIFIC STREET
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8588
Tax Map No. section 1111 .00 block 4 lot 14.001
Cross Street LEGION STREET
Issue Date: 4/25/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKc3�FFQ�.�'=
Town of Southold % COG- Application No./ al5-
Judith T. Terry, Town Clerk % x'Y y�', $10.00 - Residential
Town Hall, 53095 Main Road o ox s "<
' P. O. Box 1179 cn *1•' ..,�.;'. k $25.00 - Non-Residential
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Southold, New York 11971 u>, -,N,‘.- = -• '' '�J
Telephone *0-
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLiC.:Ti::N
for
OPERATION PERMIT .6- 1 �
SEPTIC TANK or CESSPO?, q 2 ` 1934
Operation Permit No.
Fee $ •
DATE L'lh\l'`.1
•
OWNER NAME: -175e-Qk evcArov,,r i cuv1 .
OWNER MAILING ADDRESSr`0 - off 1(-\
Ma t, c K.) Y L0.
f1 WN PR PR()PPRTV QfnREcc . Si S POk.C.�'tLc- 3-v
„ Kms.lA-A-0 ov-- Y v \ . ��
OWNER TELEPHONE NUMBER: pa_RptS1)\LC
TAX MAP NO. : Section 1 WI Block Lot ‘4 L \,
I, CROSS STREET: \-eCkt� Ea
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential ✓ Non-Residential
1 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.)
Signature of Applicant
RECEIVED BYS--c2/\
Tow Clerk's Office
DATE: l ' p� / , l' q
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