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ELIZABETH A. NEVILLE ���� y Town Hall, 53095 Main Road
TOWN CLERK � o P.O. Box 1179
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Southold,New York 11971
REGISTRAR.OF VITAL STATISTICS '�
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER
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FREEDOM OF INFORMATION OFFICER r;41southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3218 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : LISO CONSTRUCTION CORP
Address 1: PO BOX 439
City St Zip JAMESPORT NY 11947
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR ONE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. REF #R10-04-0080
Name Of Owner MOUSTAKOS, GEORGE
Mailing Address 1 705 SUNSET DRIVE
City St Zip MATTITUCK NY 11952
Property Address 1 705 SUNSET DRIVE
City St Zip MATTITUCK NY 11952
Tax Map No. section 106.00 block 8 lot 34.000
Cross Street DAISY ROAD
Building Permit Number Cross Reference:
Issue Date: 9/02/04 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ��� y�` Town Hall, 53095 Main Road
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TOWN CLERK y 2 P.O.t Box 1179
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REGISTRAR OF VITAL STATISTICS O �t Southold, New York 11971
MARRIAGE OFFICER ,n y ON-,.•+, Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER =�_4l 4 4a,' Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER .o° southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD RC::N D
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TO: Southold Town Building Department i.L u s
FROM: Linda J. Cooper, Southold Town Clerk's Office
Southold Town Clerk
DATED: July 30, 2004
Transmitted herewith is a copy of application No. 3359 for a Cesspool/Septic Tank Construction
Permit submitted by:
Liso Construction for George Moustakos
Please review the application and location map and advise if the project has received Suffolk County
Health Department approval and if this office may issue the permit.
Please complete the form below and return it to me.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE _
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Comments: j,...,- - 4 1
P2W4-4--‘41\ 14:
Signature
Dated
ELIZABETH A.NEVILLE "a• Town Hall, 53095 Main Road
TOWN CLERK ; P.O.Box 1179
REGISTRAR.OF VITAL STATISTICS Southold,New York 11971
MARRIAGE OFFICER : G '� �� Fax(631) 765-6145
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RECORDS MANAGEMENT OFFICER = # 0. ell Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER =OI "* 1' ." southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
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Residential @$10_'or Non-Residential @$25 Application No.
Permit No.
Applicant Name .- t- C' 1,/ S l C Gj " e
Applicant Mailing Address (1) t i N ` t R �� ?" `. Y `4 3 4
c4c a- l`l.`t' l'%I L(` 7,
Septic Tank /or Cesspool ✓ �,,;� �.�-D D t l �'
Brief Description of Proposed Construction or Alteration
Location of Proposed Construction/Alteration:
Owner of Property: � �' v i S M (C-6
Owner Mailing Address: 7 D 5 $ V F;-7 1)/i,
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Owner Property Address: P"` `_ ('4, s=
Name and phone number of contact person L - 7 - 7
Tax Map No: Section rod/ Block ll 8 Lot 3
Cross Street 17 I t. s c
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEP . TMENT APPROVAL
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Signature of Applicant Date
Received by: k
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PERMIT VO2 APPROVAL of .;ONSTRU TfON VOR A
w..jDo e2NGLit irAMIi RLS DENCEONLY
i do-lits o�Ei DATE 74-4)'1 H� O SG. O0.$v
. APPROVED
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:` FM MAXIMUM OF 6 BEDROOMS •
a EXPIRES THREE YEARS FROM DATE OF APPROVAL
PREPARED IN ACCORDANCE WITH THE MINIMUM
STANDARDS FOR TITLE SURVEYS AS ESTABIUSHED
BY THE MALS.AND APPROVED AND ADOPTED
FOR - USE BY THE NEW YORK STATE LAND
TITLE •. -HON.
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I UNAUTHORIZED ALTERATION OR ADDITION
TO THIS SURVEY IS A VIOLATION OF Jos. ,• pi- A.. ■._-ge�i/ -
! SECTION 7209 OF THE NEW YORK STATE v '�'1■ /�t1■
tit} EDUCATION LAW.
1 COPIES Of THIS SURVM NOT NAP NOT BEARING Land� Surveyor
THE LAND SURVIVOR'S INKED NDR
TOGBE A V SEAL SHALL NOT TRUECOPY.
BE CONSIDERED
CERTIFICATIONS INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM THE SURVEY
IS PREPARED.AND ON HIS BEHALF TO THE Tule Surveys - Subdivisions - Site Plane - Construction Layout
LENDING G INSU WTIOV HEREON.COMPAIW.GOVERNMENTAL AND
1 £ N
TD THE ASSIGNEES OF THE LEHOMG INSTI- PHONE (631)727-2090 Fox (631)727-1727
TUITON. CERTIFICARIONS ARE NOT TRANSFERABLE.
OFFICES LOCATED AT NAILING ADDRESS
THE O EASEMENTSCE OF RIGHTS OF WAY 322 ROANOKE AVENUE P.O. Box 1931
i ANY, NOT SHOWN ARE NOT GUARANTEED.
AND/OR RECORD, If RIVERHEAD. New York 11901 Riverhead, New York 11901-0965
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