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Town Hall, 53095 Main Road
���' P.O. Box 1179
® ��esr, Southold, New York 11971
JUDITH T.TERRY _ 1�����i��,•' TELEPHONE
TOWN CLERK (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. 758-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ANGEVINE, JOSEPH F. JR.
Mailing Address 1 619 BAILEY AVENUE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 619 BAILEY AVENUE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-0717
Tax Map No. section 34. 00 block 2 lot 5. 000
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 7/19/88 Judith T. Terry
Southold Town Clerk
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(TOWN SEAL)
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OFFI OF THE TOWN CLERK c��FFD(,r.'-
Town of Southold C'0 Application No. -7 SI
Judith T. Terry, Town Clerk � �►:l
Town Hall, 53095 Main Road - , Residential Lam—'
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P. 0. Box 1179 le : �'
�.:� ;.�� �� Non-Residential
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Southold, New York 11971 O ®��'^ �0� ���
Telephone *`'�j �� •'
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ id, °
DATE ,,,/10-p---
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OWNER NAME: ,J/nr / / n 41 vrrvL Ef ri.
OWNER MAILING ADDRESS: i,/5 S,4,/Q/ ,4 q42_ 1
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OWNER PROPERTY ADDRESS: .c7,9 M P
OWNER TELEPHONE NUMBER: 'l4 - //77 -® 7/7 ,, _
TAX MAP NO. : Section 3Y Block Q Lot ,S---
CROSS STREET: 'X_,,EC.x e € f SCS-, - „Pc(
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ci New Existing 2
Residential 1,--------7 Non-Residential
DATE OF PREVIOUS PUMP-OUT: A 4'o �` e-e
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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RECEIVED BY:
Town Clerk's Office
DATE:
0,47,01_:-_, 3 //_____2__r- ,_
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