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JUDITH T. TERRY .r' � Town Hall, 53095 Main Road
TOWN CLERK , 7E5? M T P.O.P.O. Box 1179
REGISTRAR OF VITAL STATISTICS "v_1 3 3ry 4; Southold, New York 11971
MARRIAGE OFFICER K ,j ""�^ y �' Fax (516) 765-1823
Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1604-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner ISAKSEN, STANLEY J. JR.
Mailing Address 1 P. O. BOX 294
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 455 KOUROS ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5835
Tax Map No. section 117.00 block 6 lot 11 .002
Cross Street GRATHWOHL ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 1/17/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK %IR/LA'
Town 'of Southold Application No. / ,o
Judith T. lerrY Town Clerk _ 1
.G $10.00 - Residential
Town/
Hall, 53095 Main Road v �'" .
p, 0. Box 1179 ' �y', "fir, f` ,. i ` $25.00 - Non-Residential
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Southold, New York 11971 Obi® 40.r,'07i
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Telephone OI
(516) 765-1801
TOWN OF SOUTHOLD
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SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit tt No.
Fee $
DATE r-L/ffJ
'OWNER NAME: ..._ t4,7 L50_4re1w) Nim,
OWNER MAILING ADDRESS: ficyX.. Z9 •
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OWNER PROPERTY ADDRESS: / J��-`k LLETOS-
OWNER TELEPHONE NUMBER: 75 5 5 ��
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TAX MAP NO. : Section / ' Block4)7Lot 1�/
CROSS STREET: Oradaia, /
TYPE OF SYSTEM: Septic Tank v1 New Existing
Cesspool 6:1) New Existing
Residential c/ Non-Residential
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DATE OF PREVIOUS PUMP-OUT: `brn e� to acs 061 /'U L /tm )
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.)
Si•na• re of Applicant
RECEIVED BY:
Town Clerk's Office
DATE: il¢CE/
Town clerk S®uolay
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