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$� Gtr ;
ct' Town Hall, 53095 Main Road
120 Ar i P.O. Box 1179
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0°. ' Southold, New York 11971
JUDITH T.TERRY ---"--....iii 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. 1540-R Residential X Non-Residential
- Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COSENTINO, CONCETTA
Mailing Address 1 15895 NEW SUFFOLK AVENUE
Mailing Address 2
City St Zip NEW SUFFOLK NY 11939-0000
Property Address 1 15895 NEW SUFFOLK AVENUE
Property Address 2
City St Zip NEW SUFFOLK NY 11939-0000
Owner Telephone No. 516-734-5168
Tax Map No. section 117.00 block 6 lot 23.000
Cross Street BUNNY LANE
Date Of Last Pump Out 0/00/00
Issue Date: 10/02/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c31FF0(,r ''
Town of Southold O CQG' . Application No. 1S4'0
Judith T. Terry, Town Clerkti; � :�
Town Hall, 53095 Main Road a �� ��� :'�
$10.00 - Residential
p. O. Box 1179 tr9 14 y `' ; $25.00 - Non-Residential
Southold, New York 11971 O 3As, -,f- •
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Telephone '`,
424_ �
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL •
Operation Permit No.
Fee VO
DATE ,kied
02I fi'D
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'OWNER NAME: Lam/ / ^ •
OWNER MAILING ADDRESS: -5' 9 $ � J /
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: / — 3 -s o
TAX MAP NO. : Section 11 �7 Block - Lot
CROSS STREET: /3,,A,,r1,- -71
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TYPE OF SYSTEM: Septic Tank New Existing
Cesspool )' New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
dA - �- -
�� 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 BY:
TowW Clerk's Office
'DATE:
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