HomeMy WebLinkAboutAquino to "-
Er) ` Town Hall, 53095 Main Road
A , P.O. Box 1179
0 4 NNT,0 Southold, New York 11971
JUDITH T. TERRY /toll 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. 1077-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner AQU I NO, ROSE
Mailing Address 1 P. O. BOX 755
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1775 GLENN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5524
Tax Map No. section 78.00 block 1 lot 26.000
Cross Street BAYV I EW ROAD
Date Of Last Pump Out 0/00/83
Issue Date: 4/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERK
Town of Southold 0 ;,eCSG; Application No. QO2
Judith T. Terry, Town Clerk ;� tt � 3 y
Town Hall, 53095 plain Road ;< Residential
P. 0. Box 1179 Er3 V.
ir ; Non-Residential
{so
Southold, New York 11971 O ®.' = •��
Telephone Q•1
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT •
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
t
OWNER NAME: 7 20 S� �/ ] 1"' 0
OWNER MAILING ADDRESS: Ri5.. i3D y 753' ‘L,�-A/,/ R p
OWNER PROPERTY ADDRESS: /?7 RI)
SOcJ7 OL D� M y, // c 7
OWNER TELEPHONE NUMBER: 73 _5391
TAX MAP NO. : Section 7 r- Block / Lot
CROSS STREET: E
5J4 I/ / k /2
y
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool New Existing V
Residential ✓ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 'ITT rn k / T 3
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.)
c
Signature of A/:plicant
RECEIVED BY:
Town Clerk's Office
DATE:
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