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HomeMy WebLinkAboutKevork n o�A��FFO`�-coG ELIZABETH A.NEVILLE o� y� Town Hall, 53095 Main Road TOWN CLERK too Z P.O. Box 1179 v' • REGISTRAR OF VITAL STATISTICS O Southold, New York 11971 MARRIAGE OFFICER �fjf'O a�� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER Telephone (631) 765-1800 FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL operation Permit No. 4276-R Residential X Nora-Residential ree $ 10.00 New x Existing Name Of Owner KEVORK DEMIRCIYAN ------------------------------ Mailing Address 1 14 FLOWER ROAD ------------------------------ Mailing Address 2 ------------------------------ City St zip VALLEY STREAM NY 11581-0000 -------------------- -- ---------- fbroperty Address 1 160 OSPREY NEST ROAD ------------------------------ Property Address 2 ------------------------------ City St zip SOUTHOLD NY 11971-0000 -------------------- -- ---------- owner Telephone No. 516-791-2913 ------------ Tax Map No. section 35.00 block 6 lot 19.000 ------ --- ------ Cross Street SNUG HARBOR ROAD ------------------------------ ---------------------------------- issue Date: 2/01/05 Elizabeth A. Neville -------- Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK %%FFO(,� TOWN OF SOUTHOLD ��� CDS Application No. ELIZABETH A.NEVILLE,TOWN CLERK ;.4 $10.00 - Residential P.O.BOX 1179 SOUI'HOLD,NEWYORK 11971 �,y�• $25.00 - Non-Residential Telephone (516) 765-1801 TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL DISTRICT APPLICATION for OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. y,;Z 7 1:o Fee $ DATE 2 /Z D /D 3 OWNER NAME:. . UQ K K JE1t412C/ y11-/y, OWNER MAILING ADDRESS: /�z OWNER PROPERTY ADDRESS: ` e� © l�S �l�ST 41) �-Db-r11,,bz_`_ /N45/, ,l!09-/ OWNER TELEPHONE NUMBER: /— ,�'/(� ��1/,ZaI/3 P, i[k.1 Ork a_ UQ j TAX MAP NO. : Section J,S�00 Block Lot- `9,00a, CROSS STREET: ffr4XQOf1 40�� - TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential Non-Residential 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.) �i✓D� Al'0 e,"?00 Signature of Applicant RECEIVED BY: own Clerk's Office DATE: " a� C , J Town Of Southold • P.O Box 1179 Southold, NY 11971 * * * RECEIPT * * * Date: 02/01/05 Receipt#: 1704 Transaction(s): Reference Subtotal 1 1 Septic Permit-Construct- Resid. 4276 $10.00 Check#: 1704 Total Paid: $10.00 Name: Demirciyan, Kevork&Janet 14 Flower Road Valley Stream, NY 11581 Clerk ID: LYNDAB Internal ID:4276