HomeMy WebLinkAboutAdipietro SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4409-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ROBERT ADIPIETRO IF—
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Mailing Address 1 2980 PECONIC LANE------------------------------
Mailing
---- -------Mailing Address 2 P O BOX 192
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City St Zip PECONIC NY 11958-0000
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Property Address 1 2980 PECONIC LANE '
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Property Address 2
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City St Zip PECONIC NY 11958-0000
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Owner Telephone No. 631-765-9156
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Tax Map No. section 74.00 block 3 lot 16.000
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Cross Street COUNTY ROAD 48
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Issue Date: 1/07/10 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
NOTICE OF INSPECTION COMPLETION
SEWAGE DISPOSAL-WATE SUPP Y
JTOLL
O Permit No. d
U
Disposal System Inspection Comple .OK to Backf
Inspection Not Completed:
O Water Supply Inspection Completed-OK to Backfill
O Inspection Not Completed:
Date Inspected by
SUFFOLK COUNTY AT NT OF HEALTH SERVICES
INSPECTION COMPLETION DO S NOT CONSTITUTE APPROVAL OF INSTALLATION
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ELIZABETH A.NEVILLEo� Gy� Town Hall, 53095 Main Road
TOWN CLERK C/a P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold,New York 11971
O
MARRIAGE OFFICER 4.4 • QFax(631) 765-6145
RECORDS MANAGEMENT OFFICER of �a Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$101 or Non-Residential @$25 Application No.l�
Permit No.
Owner Name I'l-01 P,-rU
Owner Mailing Address 7 �� �� /j� L�11L40 �j ?C.� Y 0—
/ e C-v)v
Owner Property Address �e Ce)N L L L_4 by e
Owner Telephone No.
Tax Map No: Section Block 3 Lot C
Cross Street 00 may`'1 C\_le '-�?
Please check each that applies: New Construction
Alteration to Existing System
Residential Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED 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 SCHD approval.)
Signature of Applicant Date
Received by: