HomeMy WebLinkAboutTsivourakis OFFICE OF THE TOWN CLERK • •C��FFO(x�,O
Town of Southold s�
Judith T. Terry, Town Clerk Z 4 4._.
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971 o,••,
TelephoneOlt ��
(516) 765-1801 --
TOWN
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT .
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 199 Residential x
Non-Residential
Fee $ 10.O0 Septic Cesspool
NAME OF OWNER: Peter Tsivourakis
OWNER MAILING ADDRESS: Mains Road
Orient, New York 11957
OWNER PROPERTY ADDRESS: Main Road
Orient, New York
OWNER TELEPHONE NUMBER: 516-323-2517
TAX MAP NO. : Section 15 Block 2 Lot 18
CROSS STREET: Greenway East
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing x
Replaced recently
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: 9/18/ 86
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Judith T. Terr
Southold Town Clerk
DATE: January U, 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK C.31FO(,r
Town of Southold �� CQG' Application No.
Judith T. Terry, Town Clerk .` k .4' - y
Town Hall, 53095 Main Road _:, -� Residential
P. O. Box 1179 ' ;. '= = ;' Non-Residential
Southold, New York 11971 0.O , �0 ,'�`
Telephone .( %R
V'
765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE
OWNER NAME: err,/44AliS
OWNER MAILING ADDRESS: //(/ M.041-3)
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(M/eit0 . ,Li , Irl a,r7
OWNER PROPERTY ADDRESS: in / Oee,
19/ /Z5 /(.tr /( q'r7
OWNER TELEPHONE NUMBER: 3 7, 3 2X-17
TAX MAP NO. : Section f? A.5—.00 Block Co? -CO Lot 0/1:19..000
CROSS STREET: 6-72e-E-4/ 444-7
TYPE OF SYSTEM: Septic Tank New Existing
RE
Cesspool h New 'JLACls)1 g I d-� ®'
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: ' ^/eP- ?� ,
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:
Town Clerk's Office
DATE: