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r� is � Town Hall, 53095 Main Road
�® .� .;� P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY
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. 1453-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner AGUECI, VITO
Mailing Address 1 155 ROSE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 155 ROSE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9424
Tax Map No. section 99.00 block 5 lot 20.000
Cross Street NAUGLES DRIVE
Date Of Last Pump Out 0/00/89
Issue Date: 5/09/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK .���FFp "
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Town of Southold '� C'I
Judith T. Terry, Town Clerk Application No. �y�S 3
Town Hall, 53095 Main Road • a wt° 4{'
�C 1 $10.00 - Residential
P. O. Box 1179 cn `" :A <} ► z $25.00 - Non-Residential
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Southold, New York 11971 O `® 'r 'f ��`
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Telephone QI 1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ `
DATE
466e c�G(
OWNER NAME: V / TQ (,/LL / •
OWNER MAILING ADDRESS: /'5-(5-20s� I_
m/i'''tYS�G -LTC , `q
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 676 -g-- q--9.2q
TAX MAP NO. : Section 9 Block 5- Lot
020
CROSS STREET: fc���
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool / New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /--fcj
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.)
-9> Signature Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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