HomeMy WebLinkAboutSadik ,'��,o�og�FFOt�ee
JUDITH T.TERRY ����� yj Town Hall, 53095 Main Road
TOWN CLERK ; y P.O. Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
����� Fax(516) 765-1823
MARRIAGE OFFICERCo Fax
Telephone (516) 765 1800
RECORDS MANAGEMENT OFFICER o '` l�t i
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3487-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SADIK, HALIT AND KALIROI
Mailing Address 1 103-19 68TH ROAD
Mailing Address 2
City St Zip FOREST HILLS NY 11375-0000
Property Address 1 2200 SOUND DRIVE
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 718-459-3133
Tax Map No. section 33.00 block 1 lot 16.000
Cross Street GREEN HILL LANE
Issue Date: 7/16/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/
Of FICE OF THE TOWN CLERK
Town of Southold � ,. • Application No. .SVg-7
Judith T. Terry, Town Clerk cr,z�
53095x rC 10.00 - Residential
Town Hall, Main Road 8 � $
P. O. Box 1179 u7c ,# �k, �' $25.00 - Non Residential
Southold, New York 11971 O `itis ---
Telephone Q( ,ift `A% .9
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
o r
OPERATION PERMIT
SEPTIC TANI: or CESSPOOL
Operation Permit No.
Fee $ "Es -
-
DATE
OWNER NAME: P-4/IF f- /40/r00 s
OWNER MAILING ADDRESS: / 0,3 "'t y 6r R0,4
Fr ct 4,/( JO/ 1073
OWNER PROPERTY ADDRESS : _ A;®0 _CQu\vvl 6 Y'A
OWNER TELEPHONE NUMBER: 7/4"---1157---3[33 or ..57,6--q77-4-174S-
TAX MAP NO. : Section 3.3 Block Lot I
CROSS STREET:
TYPE 3F SYSTEM: Septic Tank r/ 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, appr-ox;mately, to building and closest road.)
Signatur of Applicant
RECEIVED BY:
Town Clerk's Office �~
DATE:
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GU RANTt;F_D TO TkE HOME Til LE UIV1�"1C,i,i- • • -
CHIC _C,�J TITLE�lf ifil.;7eNt�t'r<: COMP/A•ri'Y. .-_ •
f .f.- -•-• TITI- -- r_C:,.fJ0.t8-.5.00.34 '
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. ' Ticket No. 12 0 b 1
SCAVENGER ASTE RE ORT - 01 , ',,.,'
17
Name of Hauler .. . j. f Y+ • I Load@ ..i .: Gallons
l _ Permit No: r 0 Half Load'@ " Gallons
Truck Capacity' " -,,. 'mac . 0 $ Paid
- ' (dote)
LOCATIO . 0 Slit load @ ' Gallons
' (Validation of Payment)
New 0 'epeat .. '
e
Name'of Owner ��trn .t.... ,
, - Street I ' ...; .,0.0 ':1.. -, - ..:..Bit.,
i;, Hamlet '.P --6!e. 0
r '' Telephone No. ... °� ` C11,.� Tax'Map No. " '3� .`s� .
, f ` Cross Street'
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DIAGRAM (Locate buildings and cesspool/septic system and approximate.distance in feet
between build ngs and system; give north arrow.) '
41
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I hereby certify that the above .riginated within the Town of Southold/Town of Shelter Island
-,,,, at the above location, and to t e best of my knowledge;'contains no'chemicals, hazardous, or
toxic wastes. False statements ade herein are punishable ds a misdemeanor pursuant to
Section 210-45, of the Penal L.w'of the State of New York, and may result'in'my arrest and the
,' impoundment of the vehicle I am driving. 1
Name of Driver ,4✓ .. .
Signature of Driver . t
Received by, 11.-- ' '
k,. Date . ,�-) b 6 Time, d
i4J �
(1) Treatment Plant