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HomeMy WebLinkAboutCircio rie COIF dv 4= Town Hall, 53095 Main Road i;cr ,�� P.O. Box 1179 0,o's Southold, New York 11971 JUDITH T.TERRY �.�,,,,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. 1217-R Residential X Non-Residential Fee $ 10.00 Septic X Cesspool New Existing X Name Of Owner CIRCIO, RICHARD A. Mailing Address 1 P. O. BOX 522 Mailing Address 2 City St Zip MATTITUCK NY 11952-0000 Property Address 1 CAMP MINEOLA ROAD Property Address 2 City St Zip MATTITUCK NY 11952-0000 Owner Telephone No. 021-260-2905 Tax Map No. section 122.00 block 9 lot 8.000 Cross Street CAMP MINEOLA ROAD EAST Date Of Last Pump Out 0/00/00 Issue Date: 8/25/89 Judith T. Terry Southold Town Clerk (TOWN SEAL) • OFFICE OF THE TOWN CLERK •� *'f • Town of Southold ���� d °�'e �1� Off, x� w� �G'` Application No. ) Judith T. Terry, Town Clerk Town Hall, 53095 Main Road $10.00 - Residential P. O. Box 1179 to V `'�Y� • .� �,�x;,�,y. $25.00 - Non-Residential Southold, New York 11971 O ••� ?" Telephone = j (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. Fee $ DATE 30 ,L 0- 1 OWNER NAME: �rvkC+ /D • OWNER MAILING ADDRESS: I? I 63VX 7-Uc/ / �. OWNER PROPERTY ADDRESS: fl4/1 , /1-'2/ OWNER TELEPHONE NUMBER: 3 /) —c D �cqp TAX MAP NO. : Section 1�4. Block Lot g CROSS STREET: �� -O '��J0 TYPE OF SYSTEM: Septic Tank t/ New Existing Cesspool New Existing Residential V Non-Residential DATE OF PREVIOUS PUMP-OUT: ' �0 7 �N YLu/ L- -�ov C%Yi i` 7j f , ©uS 31 C- — i�S� ~-,---7/i4 LOCATION MAP: Must be attached hereto before permit may be issued. •; /i /1 (Locate building and system; give north arrow and feet of distance, approximately, to building and closest road.) •gnature of A licant RECEIVED BY: Town Clerk's Office DATE: &,/fid C7 _ ig 13,- (_ oita - V _ �,61 -