HomeMy WebLinkAboutSagianis a;c;r
Town Hall, 53095 Main Road
���` P.O. Box 1179
=�® ,_, ..,_44, Southold, New York 11971
JUDITH T.TERRY ~'�®� ��4��, FAX(516)765-1823
--"1"..W,4111113� TELEPHONE(516)765-1801
TOWN CLERK
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. 1335-R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
New Existing X
Name Of Owner SAGIANIS, POLIXENI AND ELIAS
Mailing Address 1 23-26 CRESCENT STREET
Mailing Address 2
City St Zip ASTORIA NY 11105-0000
Property Address 1 114 CENTRAL DRIVE
Property Address 2
City St Zip MATTTIUCK NY 11952-0000
Owner Telephone No. 718-626-4762
Tax Map No. section 106.00 block 3 lot 17.000
Cross Street LUTHER ROAD
Date Of Last Pump Out 0/00/83
........444 .4.11,
Issue Date: 12/06/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
III •
OFFICE OF TE TOWN CLERK ,S�FFp `;•: 3��
Town of Southold ®% " OG Application No.
Judith T. Terry, Town Clerk «�f, ig � � .
Town Hall, 53095 Main Road - $10.00 - Residential
P. O. Box 1179 6 t -,,'i%51:0' �% $25.00 - Non-Residential
Southold, New York 11971 O-4014.'-*�', �0 `
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ / 0 ' re
. DATE /11/7/0
OWNER NAME: Toil X &iVi 4- jj / /1-S g'4 (p / 4 !"/ I
OWNER MAILING ADDRESS: g 3 `ale OR&S (... 6-3/7- s T ,�37O /Z /"
,v y //id--COWNER
/'&cOWNER PROPERTY ADDRESS: l l I/ /- t ) i V C
f/ 77it( c1-< - 1195'2-
OWNER TELEPHONE NUMBER: la 6 a 476 ,2-
AX MAP NO Section 1 O� Block j Lot / 7
01 \o ] L.v r/tC,� tr2 0 . )� J p /�
vi, ,v L\ CROSS STREET: £/1L,, /3 EA-e' �1/ ,�a ; /CI i mid'- & &3? (47 3. y
Vi V"TYPE OF SYSTEM: Septic Tank V New Existing Vii,
,Pa, '
0_ 1 Cesspool New Existing 4 /,'r.
1
J
`�� Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: rid 40 / / j Lf
Q LOCATION MAP: Must be attached hereto before permit may be issued.
"
l�IYfr� (Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
6:..1.I, (M- �--
,,,42.L
11�� 4' i0/14,t, •ii r0 11 /li V : to 11 t`
Signature of Applicant
/ RECEIVED BY: -
Town Clerk's Office `
DATE: