HomeMy WebLinkAboutCiccone �Il
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ui Town Hall 53095 Main Road
e? O ®� P.O. Box 1179
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�� .�i Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TELEPHONE(516)765-1801
TOWN CLERK
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. 1190-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CICCONE, GIACOMO
Mailing Address 1 IANNOLO, SAL
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 14 .00 block 5 lot 7.002
Cross Street RILEY STREET
Date Of Last Pump Out 0/00/00
Issue Date: 7/20/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
1. f
OFFICE OF THE TOWN CLERK COPULA' --
Town of Southold �� CQG• Application No. /7J
Judith T. Terry, Town Clerk ,
Town Hall, 53095 Main Road "�"' .0 Residential L
P. O. Box 1179 v' ;w= 'MI ;' Non-Residential
Southold, New York 11971 O ®� ``'T*0 ��`
Telephone �� '�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
nor
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ j/U
DATEAt,iC, . -c!1 Aff
OWNER NAME: /SCO /1O OCCO 4/6 —J/ 2 19.444(D?O
OWNER MAILING ADDRESS: / 9/ av_s7Sr//ey, 40,
pYr 7r p / _
OWNER PROPERTY ADDRESS: /2 /S /5 j/ j/.t,c,
.9/3-77) c,/ek / IV y //9ra
I /
OWNER TELEPHONE NUMBER: 29'4 4/0c
• TAX MAP NO. : Section MI. 0 0 Block 6,5", 100 Lot 00, oz.
CROSS STREET: 2e/ •-�i
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing (/
Residential i/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: Oa/1,Lp_ 1C/49,8/0
LOCATION MAP: Must be attached here before permit_may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
a4c,a64,10. 0..w,/
`Signature ofApplicant
RECEIVED BY•
� �-1 n Clerk's Office
DATE: JUL '
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