HomeMy WebLinkAboutKongoletoc, Diamond ',,•/litSi
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ELIZABETH A.NEVILLE �� h`Z` y�� Town Hall, 53095 Main Road
TOWN CLERK o -- P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER � �i 1 , Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER '/Ql 1G-•01
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Telephone(631) 765-1800
FREEDOM OF INFORMATION 0 I ICER ,�'� southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SO THOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4232-R Residential x Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner KONGOLETOS, DIAMOND
Mailing Address 1 36 ANNA COURT
Mailing Address 2
City St Zip WADING RIVER NY 11792-0000
Property Address 1 57958 MAIN ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 631-929-5842
Tax Map No. section 66.00 block 2 lot 2.004
Cross Street
Issue Date: 1/28/04 Elizabeth A. Neville
Southold Town clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE �`Z �G.y„; Town Hall, 53095 Main Road
TOWN CLERK 1 P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS � y, Southold, New York 11971
MARRIAGE OFFICER Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER `'*0 a� ��� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER -:'� * ,1,i southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
RECEIVED
SOUTHOLD WASTEWATER DISTRICT
APPLICATION NOV 1 9 2003
OPERATION PERMIT Southoid Town Clerk
CESSPOOL or SEPTIC TANK
c22-/ 02..
Residential @$10 or Non-Residential @$25 Application No.
3
Permit No. L i--1-q
Owner Name f v a nC, A A. and ,J 10 mo t�c nSc �eiOS
Owner Mailing Address I JCQ AWOL etJ
vex, N ( 1192
Owner Property Address 5 i R S N40.1 n ,
P Y
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Owner Telephone No. CD:a( — C;t2.q—
Tax Map No: t OC(D Section (D(e) Block 2_ Lot 2 .'T
Cross Street
please check each that applies: New Construction
Alteration toEx ting System
Residential 1/ 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.)
7(641L c C Gkf // ( dSignature/AO
pplicant i Date
:
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Received by
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LAND NOW OR FORMERLY OF LAND NOW OR FORMERLY OF
JOSEPH F KRUKOWSKI d MARYLYN KRUKOWSK DOREEN J DIGORGIO 8 RANDALL R NAL_TI
502.04'30"E SO1°38'40"E
26.48 802°04'30"E 155.00 278.02
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