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I:ZgE � '` Town-Hall, 53095 Main Road
cir '" P.O. Box 1179
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r. Southold, New York 11971
JUDITH T.TERRY '=-. r.'%!�� FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1499-R Residential X Non-Residential
, Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner TSOUNIS, CLEO, GEORGE & THOMAS
Mailing Address 1 190 CENTRAL DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 SUMMIT DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8618
Tax Map No. section 99.00 block 2 lot 14.002
Cross Street INLET DRIVE
Date Of Last Pump Out 0/00/00
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Issue Date: 7/25/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3VVFO(,r.'- '
Town of Southold ' hx.:- ra; Application No.! 7 ��9
Judith T. Terry, Town Clerk % ,---7 .40.7:! a ,:.-.1.•
Town Hall, 53095 Main Road <s '�;g :'� $10.00 - Residential
P. O. Box 1179 °'"' " `
,r ,�, � $25.00 - Non-Residential
Southold, New York 11971 O '`,
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Telephone44
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
41
Operation Permit No. -
Fee $ • -
DATE (tiT l -9-77M
'OWNER NAME: e /' -rhO6t,,9
•
OWNER MAILING ADDRESS: / 7 0 C_-r M hr q / JY , I -ei
na.:71-fift-A-Cli hfr Y1 )/ ,c.5--2..)
OWNER PROPERTY ADDRESS: -Sei'- ( °f . At 16, JP,
Al et:-/—f I 1 iii_e_,x yi / 96--,,Li
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OWNER TELEPHONE NUMBER: , l cr— 2-4 )r r
, 99-o2 'ill*
TAX MAP NO. : Section P ' K i I Block Lot 7
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing /
Cesspool V New Existing i✓/
Residential Al Non-Residential
DATE OF PREVIOUS PUMP-OUT: 1,„,..). " le„,-,0Y
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.)
_C3Q-A- fsC%-d-cl'i4^C(4 .
Signature of Applicant
RECEIVED BY: ��,Y�iiil�
"i'� Ierk's Office
DATE: JUL 20 1:
Tom Midi Southold
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R ' ,. PI2OPOSED LINE ChkANGE JULY 2CO3 1965,;2EVISED JULY 30) 19E36 1
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t to this72J0 survey is t violation of I TEED O .~ _ ----_-�. _ _.--11-___-_ -. - . --- -.--_ ———
/� ' •�— � tianaa��t� �a � t�t� U{�IA3�.i7" .Ev TO i ECC?r� TI "LtJ�.` s � F{ Co,. I`"rtCrIJ �� Iii t
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�� -� . , Copies cf this survey me iiTR21 a, ew ?�2€d et 4 acing JA��1' Neat or .a �j�-�I`'s'� _" A5 ...��Y t',�'��r :J JULY 16, 1 8•-3
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errs seal shall net to considered > } r T�
1� to a valid true copy. 1,.._.\._JD i.f l ti}ti.1 l,_ \J I + : F/' ..r T", i�.,.
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t {^ �j (' /� i tsuarenaema inir_ tcd hmsecra a all run
:• .-.�. K �` ;..F� TO MAP OF CAPTAI i ` �1 r•� f h °. r T t i t 1 tom. is prepared.in arca and o for wham th thesurrey - _
C- '' ^ 1` ,i N k. 1 L_0 ESTAT ES F4 Lt�..1.. is only
tot and an his behalf z sur
r (��j OFFICE / q �j NO- 1672. title company,governmental op ncy and - �� �°
7-H E Su f" F, cO�,o-,.L t....k 1,:::, A MAP lend=institution riatec;hereo, and v�`ss�� ,.. -4 - f
to the aas,gne e, of the lending insib-
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I rr [`^ CO. f�,/��, ('"'� �} �}� tunon Gua"emcee ars nos.transferable �`� -
f t' 7-l_J E""' f ..COTAY, ',\/1 \,P i!'�,.P' � ATA : 10-Q0 -99-2^14. m^ot'dreonal lnstitutlonb o subsequent '
_____ _ _- __ __ owners.
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