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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK F P.O. Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
® t Fax (516) 765-1823
MARRIAGE OFFICER �' $$ Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER --�Q1iff •0
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 1223 R Residential X Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : EAST ISLE CUSTOM BUILDERS INC.
Address 1 : 278 JAMAICA AVENUE
City St Zip MEDFORD NY 11763
Descripton of Proposed Construction or Alteration
SANITARY SYSTEM FOR NEW SINGLE FAMILY DWELLING.
APPROVED AS SUBMITTED AND AS APPROVED BY THE SUFFOLK COUNTY DEPARTMENT
OF HEALTH SERVICES. SCHD REF. #59-3-18
Name Of Owner THEOPHILOS, N & SPYPOPOULOS, K
Mailing Address 1 C/O EAST ISLE CUSTOM BUILDERS
278 JAMAICA AVENUE
City St Zip MEDFORD NY 11763
Property Address 1 KENNY'S ROAD
City St Zip SOUTHOLD NY 11971
Tax Map No. section 59.00 block 3 lot 18.000
Cross Street MIDDLE ROAD
Building Permit Number Cross Reference:
Issue Date: 10/13/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
/32 013
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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERK :____
P.O. Box 1179
t �� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS .. e% Fax (516) 765 1823
MARRIAGE OFFICER ` ® tRECORDS MANAGEMENT OFFICER 4 J �I��� Telephone (516) 765-1801
FREEDOM OF INFORMATION OFFICER .�.ii,1,r11l
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OFFICE OF THE TOWN CLERK �f �_ (� tea_
TOWN OF SOUTHOLD
if � � iii'',`I OCT 5 0 . r
TO: Southold Town Building Department i _ 4 1`_ 1!�
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FROM: Linda J. Cooper, Southold Town Clerk's Office ''- TQW L®G JDEi
OF 5��.��QLD I
DATED: October 4, 1994
Transmitted herewith is a copy of application No. 1267 for a Cesspool/
Septic Tank Construction Permit submitted by:
East Isle Custom Builders Inc. for Theophilos and Spypopoulos
Please review the application and location map and advise if the project
has received Suffolk County Health Department approval and if this office
may issue the permit.
Please complete the form below and return it to me.
Thank you.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above
and make the following recommendations:
APPROVE Z/
DISAPPROVE
Comments: .. .,2,-, :: /39,- 3,-z-G p
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Signature
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Dated
,
OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk Application No.•�
Town Hall, 53095 Main Road Construction
P. O. Box 1179
Southold, New York 11971 Alteration
./
Telephone Residential
(516) 765-1801 Non-Residential
TOWN OF SOUTHOLD
• SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE •
APPLICANT NAME: �1157---- L sez=SC/�S -(/14-c..i.76RS 2-4./(-
APPLICANT ADDRESS:-2-7 -49-e- 414,4 /4)'
(&)Po L ) AP/ //7 6.3
SEPTIC )C CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
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LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: Af/cke_T E:opi-l)LoS vq,Th cA)2Ds -47J?6im-1-OS
OWNER MAILING ADDRESS: v �d-4S5--.iSL� c5-oze.‹ # i 7 S :Zees
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OWNER PROPERTY ADDRES : GC 1/S XC.84AJ1V S Z A90244 170 /
AJle, �"l a,1 i CG— (Z ) ( SZ-r- vg) Soc --i-1oA
TELEPHONE NUMBER OF CONTACT PERSON: 72-7— tD Z3
TAX MAP NO. : Section Se? Block j Lot /?
CROSS STREET: ilisT)aG� AM.
BUILDING PERMIT NUMBER CROSS REFERENCE:
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Le ..A: CS-2.574A_I
/ -`i na .1- of Applicant
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RECEIVED BY:
Town Clerk's Office
DATE:
,Sc.T M. /t/o. /OOO- 59 -3-/8
5u/4✓Ey&O FOR 7/Ioiyj4'S ¢ /IIOREEN //qnrL/M SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
` ,ORoPERTy LOCATED AT „OciT/-/oL0 \
' 7-0W A/ Of Sou7NoL5 FOR APPROVAL OF CONSTRUCTION ONLY SINGLE FAMILY DWELLG ONLY
,5 cUFFO L K COUNTS New Sof - G�' ��j y �l, _q,/ �,E WIRES THREE YEARS FROM DAT OF APPROVAL
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