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JUDITH T.TERRY 11 fi, Town Hall,53095 Main Road
TOWN CLERK
P.O.Box 1179
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REGISTRAR OF VITAL STATISTICS • Southold,New York 11971
MARRIAGE OFFICER ��; ®�� , Fax(516)765-1823
RECORDS MANAGEMENT OFFICER d �,„ to° Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,i•s'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3354-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner VASKELIS, AMELIA C.
Mailing Address 1 80 JERNICK LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1220 RAMBLER ROAD
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2824
Tax Map No. section 88.00 block 5 lot 16.000
Cross Street PLEASANT PLACE
Issue Date: 6/13/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK ' c0FOL,�
Town of Southold � ,.: C0 = Application No.33 � /
Judith T. Terry, Town-Clerk' y' —
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Town Hall, 53095 Main Road ,..x., < $10.00 - Residential
P. O. Box 1179 c•r' ` ::•� �= € i ; $25.00 - Non-Residential
Southold, New York 11971 O ® . 0���1
Telephone Q( $�
(516) 765-180144 0
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
• • OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
6
Fee $ 10
DATE'—J 1'01; la I ct q(
'OWNER NAME: j `qVA-5. KE" LIS
OWNER MAILING ADDRESS:_4/..) ? f e J iQ Sbu J.c) yu1 I (F7
OWNER PROPERTY ADDRESS: /
OWNER TELEPHONE NUMBER: 7 .5'-
TAX MAP NO. : Sectio ' ge Block L Lot /
CROSS STREET: —PILE,A-;C'Ptpt.,KJ-GE J 0 / /(y0
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential , Non-Residential
DATE OF PREVIOUS PUMP-OUT: 3 ^ / - (fiRS- 1- r 6")
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.)
Signa re of Applicant
RECEIVED BY:
Towiedsitos Office
DATE:
JUN 151995
Ion Clerk Soda
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