HomeMy WebLinkAboutBauso, Greg (2) ELIZA Aj_1V� �r Town Hall, 53095 Main Road
T(�WPT;•CLE ��.--1 � _ 1 P.O.Box 1179
REGISTRIAAW�ibITAL� TEAT ST fi'• ® Southold,New York 11971
MAI �GE•OFl?IGER _^= �` Fax(631) 765-6145
RECORDS {AG}sMEj�F tiei I ®� +�® Telephone(631) 765-1800
FREEDOM ObRM�T FR southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERAUT
CESSPOOL,or SEPTIC TANK
Residential @$10,or Non-Residential @$25 Application No. %So
Permit No.
Owner Name
Owner Mailing Address_ l,-29 �'7
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Owner Property Address_ 9/60 mF},n -R
Owner Telephone No. r1l R S Qj--91(G
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Tax Map No: 16CO Section 31 e Bleck Lot
Cross Street s.s fit/ C7 �(� 3
Please check each that applies: New Construction X
Alteration to Existing System
Residential�—Non-Residential
NOTE., LOCATION MAP MUST BE SUBAUTTED WITH APPLICATION_ (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCUD approval.)
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Si ature of Applicant Date
Received by:
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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4496-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner GREG BAUSO
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Mailing Address 1 128 67TH ST
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Mailing Address 2
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City St Zip BROOKLYN NY 11220-0000
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Property Address 1 9100 MAIN ROAD
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Property Address 2
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City St Zip EAST MARION NY 11939-0000
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Owner Telephone No. 718-875-8160
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Tax Map No. section 31.00 block 8 lot 3.000
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Cross Street BAY AVE
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Issue Date: 10/19/16 El zabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)