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Town Hall, 53095 Main Road
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P.O. Box 1179
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JUDITH T.TERRY 7"._ ��� 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. 1399-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CONRARDY, SALVATORE JOSEPH
Mailing Address 1 1380 JOCKEY CREEK DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1380 JOCKEY CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2314
Tax Map No. section 70.00 block 5 lot 16.000
Cross Street GILBERT STREET
Date Of Last Pump Out 0/00/00
Issue Date: 3/01/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK •
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Town of Southold 5, A-. C'Q - Application No. /3
Judith T. Terry, Town -Clerk gWxy
Town Hall, 53095 Main Road t, �'ya 1 $10.00 - Residential (Y----
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�P. O. Box 11797 x � *
Southold, New York 11971 0 `® Fla'°' - -�J� $25.00 - Non-Residential
Telephone .���►••
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TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
. DATE z ` 2- la, - %r7
OWNER NAME:4-ajarwfrti ',1. , 4- • .
OWNER MAILING ADDRESS. ze 6 <ley £/2--cA-A- DU,-
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OWNER PROPERTY ADDRESS: s) �ti a‘ /1
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OWNER TELEPHONE NUMBER: 6-7 6 - 7 C S"- r 2
X3/471
y TAX MAP NO. : Section 70 Block Lot /10
CROSS STREET: r'J
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - New Existing
Residential /---- Non-Residential
DATE OF PREVIOUS PUMP-OUT: /"-- i - 10
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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Sig+atu /'of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE:
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