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JUDITH T. TERRY AT 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
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Fax
(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1984-R Residential X Non-Residential
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner PALIOS, EMANUEL & IRENE
Mailing Address 1 154-22 20TH ROAD
Mailing Address 2
City St Zip WHITESTONE NY 11357-0000
Property Address 1 560 CAPT. KIDD DR.
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5829
Tax Map No. section 106.00 block 2 lot 52.000
Cross Street INLET DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 10/05/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY j q Town Hall, 53095 Main Road
TOWN CLER1t t, P.O Box 1179
REGISTRAR OF VITAir;STATISTICS
Southold, New York 11971
c/ '‘' Fax (516) 765-1823
MARRIAGE OFFICER ®�y�® ;*� Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1984-R Residential X Non-Residential
Fee $ 25.00 Septic Cesspool X
New Existing X
Name Of Owner PALIOS, EMANUEL & IRENE
Mailing Address 1 154-22 20TH ROAD
Mailing Address 2
City St Zip WHITESTONE NY 11357-0000
Property Address 1 560 CAPT. KIDD DR.
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5829
Tax Map No. section 1 .06 block 2 lot 52
Cross Street INLET DRIVE
Date Of Last Pump Out 0/00/00
Issue Date: 10/05/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'cOFOCA-
Town of Southold �• C'G' Application No. l s--K
Judith T. Terry, Town Clerk ' ' '`
Town Hall,, 53095 Main Road ~ '� :'� } $10.00 - Residential
p. C: Box 1179 ; WI* i ; $25.00 - Non-Residential
Southold, "� < ,i'"` ',
New York 11971 O � #- �/r
Telephone.( ,l It 1 .
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /97(
Fee $ /0 ,------
DATE ./ / r ( 7 / 1 f a..
OWNER NAME: 6q,,it,{_.t„Q-�Q,, ` q1.14a a ii„&e...)
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OWNER MAILING ADDRESS: 6 ,41, .--'_,l' .: ,tIg)-2--e...z.Le
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OWNER PROPERTY ADDRESS: (-1
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OWNER TELEPHONE NUMBER: c 9 sr`-- � -f l.� 3 o fgl- ICC2t---a D.- olomfect , Afl___-e _+_,97zze ,Ny�
j TAX MAP NO. : Section 1 0 6, Block ._ 'Lot '4- `. ,
CROSS STREET: _ ... �/ , " .a i� =�;c�
_
TYPE OF' SYSTEM: Septic Tank i New Existing V
Cesspool J New Existing / ,
Residential I Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
4 .1710//441(te 90/;--5-3
Signature of Applicant
RECEIVED BY: di - . _ _
Town Clerk's ffice
DATE: C" /J 7g 't_____-
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