HomeMy WebLinkAboutFokas N Town Hall, 53095 Main Road
��,�e® O ) P.O. Box 1179
I���� ®� s2-L.33s22j� %� Southold, New York 11971
JUDITH T.TERRY `� — TELEPHONE
TOWN CLERK , _ (516) 765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3566-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner FOKAS, ANDREAS
Mailing Address 1 P. O. BOX 799
Mailing Address 2
City St Zip EAST MARION NY 11939-0000
Property Address 1 8765 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 516-477-8904
Tax Map No. section 31 .00 block 3 lot 15.000
Cross Street
Issue Date: 12/27/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'� .. ...�'
OFFICE OF THE TOWN CLERK �1FFU
Town of Southold ��� CSG Application No. 06
Judith T. Terry, Town Clerk •� ;� %1 R
$10.00 - Residential
Town Hall, 53095 Main Road
P. O. Box 1179 cn �: F. �� $25.00 - Non-Residential
Southold, New York 11971 O /-`
Telephone 0.( ' .�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ .O
Qi
DATE I I '1&, \
't
OWNER NAME: (\`n CQC\S VDYG.S
OWNER MAILING ADDRESS: yi (ofD He cc C2.00kof
s� Nosko , Ny 1tC )°(
OWNER PROPERTY ADDRESS: ed
OWNER TELEPHONE NUMBER: (5R') 417 -&-q01-1
TAX MAP NO. : Section 1-2St8 Block ?j\ . Lot - S- )
CROSS STREET:
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.)
ON,
/ldi 112-,eX-4Cri
°"Sig ure of Applicant
RECEIVED
11, RECEIVED BY:
Town Clerk's Office
DEC 2 7 1996
DATE:
Solztthold Taw C!erk
'":=„e;,..,';','
r *11'4 S'A
TOWN OF SOUTHOLD
Ticket No.
SCAVENGER WASTE REPORT -so ,0-,
Name of Hauler v �2,e,e/ ,,,� ✓ ,�i`�'. , j •
Permit No. �? rule Load @ 1' Gallons
0 Half Load @ : ;;:
Truck Capacity �, Gallons °'
❑ $ Paid '
(date) ''
0 Split load @ Gallons
1:1 New L7 Repeat (Validation of Payment)' '
LOCATION: ' ',
Name of Owner /!/
Street .7,(e.$:'. , ! �,
Hamlet � `7r- 11!Ll.. J
Telephone No. ... :,•l••-= SQic Tax MapSi--- 2
No. „ y........
Cross Street
DIAGRAM (Locate buildings and cesspool/septic system and approximate distance in feet
between buildings and system;give north arrow.) "�
, - , .. I. ' Al
4..1 ,,,, .
. .
.,,i(62---I--- ------4 .
..-..,V. -
, ,.
1, .
71:. ..,,,fi . .
„ . r,
I hereby certify that the above originated within the T wn . ,. . s'
at the above'location, and to the best of m knowlecn of Shelter Island ', ,,t' r'"%
' toxic wastes.' False statements made herein•are punishable as a misdemeanor pursuant to or
Section 210-45 of the Penal.Law of the State of New York, and may result in my arrest and the
impoundment of the'vehicle I am , ng.
/ .• Y.
Name of Driver b
Signature of Driver
-
'
Received b % tis"
bate ' 11 '0 2-6 )
Time ! a
' (1)Treatment Plant #
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