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� Town Hall, 53095 Main Road
P.O. Box 1179
®//yy �OO��i'� Southold, New York 11971
��� s2 ' I.1�,F FAX(516)765-1823
JUDITH T.TERRY _x,50~` 1 TELEPHONE(516)765-1801
TOWN CLERK
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. 1401-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BOSCOLA, DAVID
Mailing Address 1 P. O. BOX 587
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 770 MEADOW LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8381
Tax Map No. section 115.00 block 4 lot 28.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 3/05/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK cvFFO(.� --
Town of Southold C /�O/
�' � QG Application No.
Judith T. Terry, Town Clerk -*
Town Hall, 53095 Main RoadL << .- $10.00 - Residential V
P. 0. Box 1179 j t j > h, �
$25.00 - Non-Residential
Southold, New York 11971 �,I® `��•
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Telephone Q( � i
(516) 765-180144 P
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /o.0)
•
DATE la, � H.94)
OWNER NAME: JAUI!) /3OSCOLA •
OWNER MAILING ADDRESS: PO • Bax# 5E7
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OWNER PROPERTY ADDRESS:` O inc ow IAN(
MATrtivo , A)'f'. /J65
OWNER TELEPHONE NUMBER: 29 ?321
TAX MAP NO. : Section /f 5 Block Q Lot 62?
CROSS STREET: NO) SFroLk AlU7ule r
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
. Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: DPCpypkir 119 9
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
�-- CJ7lJLtM&L of distance, approximately, to building and closest road.)
Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
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