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JUDITH T. TERRY A ` t• Town Hall, 53095 Main Road
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P.O. Box 1179
TOWN CLERKS ® dpi
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER �® @� '41. Fax (516) 765-1823
���� ® ! Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1973-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CORSO, CAMILLA
Mailing Address 1 750 LUPTON POINT ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 750 LUPTON POINT ROARD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4379
Tax Map No. section 115.00 block 11 lot 17.000
Cross Street MARRATOOKA ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 9/21/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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`OFFICE OF THE TOWN CLERK 0c31HO( ' ��
Town of Southold 73
0�� . 4 ea -- , Application No.
Judith T. Terry, Town Clerk ' a, 6. y
Town Hall, 53095 Main Road -� 1 $10.00 - Residential
P. O. Box 1179 - . 'moi $25.00 - Non-Residential
Southold, New York 11971 O ®. = ��`
Telephone ��� '��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL •
Operation Permit No.
Fee $ !4‘ .
/
DATE ,I.
OWNER NAME: a.4.,,,
az,,,,,S., 1
OWNER MAILING-ADDRESS: 7c/ :r ----- --- - -- -
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OWNER PROPERTY ADDRESS: ,,c A- -a.....J� t
1 "12 1 ii q,3-9--
OWNER TELEPHONE NUMBER':_ Et_ .2,9k- L/3 l ,9
y TAX MAP NO. : Section / l/ Block If Lot J 'f
CROSS STREET://e0}4,',X0-44., ei
TYPE -OF; SYSTEM: Septic Tank --" " "" -"New Existing
�,Cesspool New Existing ,
- Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: _.-..t 90
,..A.e. ,-. •
LOCATION MAP: Must be attached hereto We'fore permit may be issued. ,
' (Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
.a- atUe
QJ
,-2Signature of Applicant
RECEIVED: BY::: _ _
Town Clerk's Office
DATE: • , _, _
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