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JUDITH T.TERRY ���1,•%. Town Hall, 53095 Main Road
TOWN CLERK % Z P.O. Box 1179
^T � Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ®�
MARRIAGE OFFICER ��� Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER _�f ' ` ®��'� Telephone (516) 765-1800
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FREEDOM OF INFORMATION OFFICER ,•"
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3453-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ANNUNZIATA, ANTHONY
Mailing Address 1 296 SUMMIT AVENUE
Mailing Address 2
City St Zip MT. VERNON NY 10552-0000
Property Address 1 230 EAST ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000 •
Owner Telephone No. 516-298-8219
Tax Map No. section 106.00 block 3 lot 4.000
Cross Street BREAKWATER ROAD
Issue Date: 4/10/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 'c3IFU '?-
Town of Southold � CQG_, Application
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -< $10.00 - Residential
P. O. Box 1179 ;` $25.00 - Non-Residential
Southold, New York 11971
Telephone -_611 11/4W����,
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /Q •
DATE 1/7)//9 �
OWNER NAME:)-l e--vA7 /v7 /'a /1 r l< V �_
OWNER MAILING ADDRESS: r a �/ b pct r)-->r)-1 ( 7AL-e-
-
dL-e- I/e_irLcr,ti_ Al
OWNER PROPERTY ADDRESS: "r( •
OWNER TELEPHONE NUMBER: 6/6 -
TAX MAP NO. : Section l()6 Block 'j Lot
CROSS STREET: re (t K t.0 a err
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential V Non-Residential
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.)
• 444111P •
Sig rte. Applicant
RECEIVED BY:
Town Clerk s Office
DATE: 47 A//- 6
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