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Town Hall, 53095 Main Road
;�,� *.$ P.O. Box 1179
_Q( lit `�� -��/II° Southold, New York 11971
JUDITH T. TERRY +���, "Po TELEPHONE
TOWN CLERK (516)765-1801
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. 1096-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner RETZOS, KIMON
Mailing Address 1 84-14 143 STREET
Mailing Address 2
City St Zip JAMAICA NY 11435-0000 •
Property Address 1 NORTH ROAD
Property Address 2 ROUTE 1, BOX 62345
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 718-658-6172
Tax Map No. section 40.00 block 1 lot 5.000
Cross Street CHAPEL LANE
Date Of Last Pump Out 0/00/00
Issue Date: 5/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK �� FD
Town of Southold 0�� _�:n , `'�... Application No. l6
Judith T. Terry, Town Clerkrr" ;+ y
Town Hall, 53095 Main Road a ; }« '*?3''. ".':. - 1 Residential c../
P. O. Box 1179 v' , ��^ i ; Non-Residential
Southold, New York 11971 rOr'••�
Telephone IA(
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(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for -
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. /o?Q
Fee $ /O "�
DATE 0,7 a) /9/F9
• OWNER NAME: j,,n7) k_e4eTrti
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OWNER MAILING ADDRESS: ?AI_ /g ,/� Abicp_e
4/k a.,f may► o //4434-
OWNER PROPERTY ADDRESS: J� _, I (3.6--X �/�
,Q2t- mac± //?9
OWNER TELEPHONE NUMBER: 6/q).- /142.
TAX MAP NO. : Section 146 - 1— C
Block Lot
CROSS STREET: .L
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: at iv-a4.) Au/v-&t,
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.)
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Signature of<• pplicant
Rs
MAY 05 1969
RECEIVED BY:
/0 -Te.it 4i 4 1'kis Office
DATE: dA %t z.c,. t
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