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JUDITH T. TERRY �� Town Hall, 53095 Main Road
TOWN CLERK I _ = i P.O. Box 1179
REGISTRAR OF VITAL STATISTICS : T Southold, New York 11971
MARRIAGE OFFICER t y �'% Fax (516) 765-1823
eo, �®��• Telephone (516) 765-1801
=, 141 $ 70.
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1657-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANGELO, JANICE
Mailing Address 1 45 HORTON AVENUE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 45 HORTON AVENUE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5376
Tax Map No. section 141 .00 block 1 lot 37.001
Cross Street SH I RLEY ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OF''FFICI= OF THE TOWN CLERK
0c3-- Application
Town of Southold 0 C = A lication No. Jf/
-3
Judith T. Terry, Town Clerk . D� PP
Town Hall, 53095 Main Road rT :,s .G $10.00 - Residential
� - ;
P. O. Box 1179 �:,4� �,. . '� $25.00 - Non-Residential
Southold, New York 11971 O - 4
Telephone -..62 4
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 7)., i! v
DATE
OWNER NAME: j /(DICe e 0 •
OWNER MAILING ADDRESS:1/ 5 kola
♦ � � —
OWNER PROPERTY ADDRESS: �4 ' ()L
OWNER TELEPHONE NUMBER: 670 a?ig--- , 7
TAX MAP NO. : Section Block Lot
CROSS STREET: /)
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing Xi
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
Sign- ire of Applican• /
RECEIVED BY:
Town Clerk's Office
DATE:
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