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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER %,-*)
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. 1891-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New X Existing
Name Of Owner GAZOULEAS, PANAGIOTIS J.
Mailing Address 1 1374 MIDLAND AVENUE
Mailing Address 2
City St Zip BRONXVILLE NY 10708-0000
Property Address 1 960 WILLIS CREEK DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-765-5389
Tax Map No. section 123.00 block 10 lot 1 .000
Cross Street MEADOW BEACH DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 4/28/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK cl\VFO(,(--'-
Town of Southold �� CQG' , Application No. / ? 7/
Judith T. Terry, Town Clerk . t €
Town Hall, 53095 Main Road - $10.00 - Residential
k A S
p. O. Box 1179 cry `.F- $25.00 - Non-Residential
Southold, New York 11971 O ; '
Telephone.(" ���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE rill
OWNER NAME: G'► zo,,c Elq `.s_7 tv ; *Tis
OWNER MAILING ADDRESS: i3 '7C,g ,,,`( ,� ✓ /
/O7Oa
OWNER PROPERTY ADDRESS: 9 (po L ) c c Cr2t iC p
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section • Block /0 Lot /
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New ›c Existing
Cesspool New Existing
Residential )C Non-Residential
DATE OF PREVIOUS PUMP-OUT: A
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.)
•
'gnature o Applicant
RECEIVED BY: �(J'/�X/f '�
o n• Clerk's Office
DATE: ii /g. g ��
The
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N.twage disposal HS R ' 7eTsto arftis'r0deri;e a71 Conformxto the:eta srd'
41,ffelk Calmly
I e®ris,of'ra�el/s .
a . CG8 . e�r�oGis-shore e from field '40
obber�a�tlens and or from data is ,.,A if. . .-•Y; s r - :1
BUILDING ZONE � 7'RICT .�_� SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
FIRM ` FLOOD ZO Cjil
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/�� .�� DATE t vLq�A��ILY DUELLING ONLY
is__ H.S. REF. NO. -/ _
The'Sewage disposal and water supply facilities for this '
location- . •en in fected by this a artm '� `l`.0/ •w 1,4 fl,',V:::::,-
other location-1:
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