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� ��: Southold, New York 11971
V%JUDITH T.TERRY ~r_ ®� FAX(516)765-1823
TOWN CLERK %a�oviai'�i1�`� 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. 1398-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CICCONE, GIACOMO
Mailing Address 1 IANNOLO, SALVATORE
Mailing Address 2 141 WESTBURY AVENUE
City St Zip MINEOLA NY 11501-0000
Property Address 1 1215 BAY AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-294-8105
Tax Map No. section 143.00 block 5 lot 7.002
Cross Street RILEY AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 3/01/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
• •
OFFICE OF THE TOWN CLERK , C.SFO(,r��'
Town of Southold C� = Application No.J3q
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road _ $10.00 - Residential
P. 0. Box 1179cra
�z `" f $25.00 - Non-Residential
Southold, New York 11971 ® ® =' '
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. --
Fee $ ® j `
DATE .4-i\ (311)
OWNER NAME: cco 11_ j \et-coo/Lc), v o o ) b • S44 0/Q 4a"2.0
OWNER MAILING ADDRESS: 01, u 14 I A-
\`11
\11 I`, 6 0sa IYS. 0 t IN
OWNER PROF.-.v.T^. Ar-D:11-7(7c Q, 1 5 A4,1 v
OWNER TELEPHONE NUMBER: 15. 1 (:) -- 02. I3 l.J - FC 1 Os
TAX MAP NO. : Section 0 l v O Block (5 5 , 0 0 Lot CD O . D® c�—
CROSS STREET: RI t- C
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New c/ Existing a/
Residential r/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: J4 LVj Lit 8
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.)
_Lair
ignature .f Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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