HomeMy WebLinkAboutSellis •-
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JUDITH T.TERRY �� _ Town Hall, 53095 Main Road
TOWN CLERK % P.O. Box 1179
1,ivy Southold,New York 11971
REGISTRAR OF VITAL STATISTICS Fax(516) 765-1823
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER - 491iNg � Telephone(516) 765-1800
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. 3445-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner SELLIS, ATHENA
Mailing Address 1 223-11 59TH AVENUE
Mailing Address 2
City St Zip BAYSIDE NY 11364-0000
Property Address 1 11600 MAIN ROAD
Property Address 2
City St Zip EAST MARION NY 11939-0000
Owner Telephone No. 718-631-9264
Tax Map No. section 31 .00 block 14 lot 1 .000
Cross Street
Issue Date: 3/12/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
t -
OFFICE OF THE TOWN CLERK oSU�FotA
Town of Southold �o CQG=� Application No. 3 Y
Judith T. Terry, Town Clerk 6. y
Town Hall, 53095 Main Road a -< $10.00 - Residential
P. O. Box 1179 tn - $25.00 - Non-Residential
Southold, New York 11971
Telephone '14 '��
(516) 765-1801
TOWN OF SOUTHOLD •
'
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT ;
SEPTIC TANK or CESSPOOL
Operation Permit No. ,
•
Fee $ / `
DATE 3422/9‘
OWNER; NAME: 40 it 7
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OWNER 'MAILING ADDRESS: ""jj 5-7
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mys i *11 liry. e& A y
OWNER_PRO.PERTY -AD_DRESS: __ ___ !/______ _ _ _ _ -_ _ 42-P34 R I
OWNER TELEPHONE NUMBER: '>/' (o' Y
TAX MAP NO.. : : 'Section / 3 r87 Block Lot '
• 0 CROSS STREET: .
TYPE OF SYSTEM:,:-";SepticJaRk' _ _ New Existing
Cesspool - 'lam 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.)
- Signature of Applicant .
RECEIVED BY. . .•,�Rl .,, - . ---- - ---- -- � , _ - -_-_ _.__.. __ , __• ... .- .
c s , , Tpwn ,Clerk's Office _ „
DATE: 0 '
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