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JUDITH T.TERRY 1� 7k ' d • Town Hall,53095 Main Road
TOWN CLERK u -"C-`,$11P.O.Box 1179
REGISTRAR OF VITAL STATISTICS 1�
MARRIAGE OFFICER ` $'s Southold,New York 11971
�� Fax(516)765-1823
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RECORDS MANAGEMENT OFFICER = 1 ^ �`jsdl Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER -• Vo
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3374-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KONTOVEROS, EMMANOEL
Mailing Address 1 1095 WESTPHALIA ROAD
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1095 WESTPHALIA ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9603
Tax Map No. section 141 .00 block 2 lot 20.000
Cross Street MIDDLE ROAD
Issue Date: 8/10/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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QFFICE OF THE TOWN CLERK SSFOLA':-
Town of Southold CQG Application No. 53,374(
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road -� a $10.00 - Residential
P. O. Box 1179 v' • i ;) $25.00 - Non-Residential
Southold, New York 11971 4 �P�
Telephone sN •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10 ¢ 00
DATE g --cr- 7s-
OWNER NAME: g)0,40106L..- tOvfOV6
OWNER MAILING ADDRESS: /O S ea)5STFFJ19c,, IT(..-11213
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: C5 ) j3, q 9' 60
TAX MAP NO. : Section /64/ / Block 2 Lot 2 0
CROSS STREET: j .yp '(' i
TYPE OF SYSTEM: Septic'Tank �I _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.)
642 2.iL�Q2 Pdi
S`�ignature o pplicant
RECEIVED BY:
•
Town Clerk's Office
DATE:
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