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JUDITH T. TERRY : Town Hall, 53095 Main Road
TOWN CLERHP.O. Box 1179
Southold, New York 11971
REGISTRAR OF'VITAL STATISTICS
® Fax (516) 765-1823
RECORDS MANAGEMENT OFFICER
MARRIAGE OFFICER �'n Y t® 6$� Telephone (516) 765-1801
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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. 1179 R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
PERMIT ISSUED TO:
Name : STANLEY F. SKREZEC
Address 1 : 50 GULL POND ROAD
City St Zip GREENPORT NY 11944
Descripton of Proposed Construction or Alteration
ADDITION OF A CESSPOOL TO AN EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT WELLS
BUILDINGS, PROPERTY LINES, AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED.
Name Of Owner TOURTOULIS, ADAM
Mailing Address 1 21-69 38TH STREET
City St Zip ASTORIA NY 11105
Property Address 1 221 CHAMPLIN PLACE
City St Zip GREENPORT NY 11944
Tax Map No. section 34.00 block 3 lot 38.000
Cross Street STERLING PLACE
Building Permit Number Cross Reference:
Issue Date: 8/05/94 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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JUDITH T. TERRY �, Town Hall, 53095 Main Road
TOWN CLERK ® P.O. Box 1179
:� Southold, New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER ®��.* Fax ne(516)(516)765-182365-1
RECORDS MANAGEMENT OFFICER ®/ �� r�' Telephone 765 1801
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FREEDOM OF INFORMATION OFFICER "+ ��������i���
OFFICE OF THE TOWN CLERK Q a
TOWN OF SOUTHOLD . 0
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TO: Southold Town Building Department ; --
FROM: Linda Cooper, Southold Town Clerk's Office 0_ =
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FROM:
August 3, 1994
Transmitted herewith is a copy of application No. A1227 for an
ALTERATION PERMIT for a cesspool or septic system submitted by
Stanley F. Skrezec for Adam Tourtoulis .
Please review the application and location map and advise if this office may
issue the permit.
Please complete the form below and return it to this office.
Thank you.
4- - -e GCS
Linda J. Cooper
* * * * * * * * * * * * *
I have reviewed the application and location map of the project listed
above and make the following recommendation:
APPROVE - ,g VATION INSPECTION
DISAPPROVE - r?gQ Ui T;, Ft
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OFFICE OF THE TOWN CLERK •,,,,,""-'
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Town of Southold i* \vier • -
Judith T. Terry, �° Application No. °2 7
y Town Clerk �' 0•y._ G�
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Town Hall, 53095 Main Road Construction
P. 0. Box 1179 ; =v
Southold, New York 11971 eta ;� �� Alteration t-/
Telephone ri � � $10.00 - Residential
(516) 765-1801 -_ .1 D ' $25.00 - Non-Residential
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No.
Fee $
DATE &t-I5 2( 1jOL
APPLICANT NAME: lA-t3Loy S �C—
APPLICANT ADDRESS: SO C.DL,L_ c:7®p 0 L_ cam.;
SEPTIC CESSPOOL
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION ADD 4-
0 c.._ `C2) e S Cesyw- U.L
114) e4- ibojt, `� 6 42 re. -. -
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION:
OWNER OF PROPERTY: A-S)/ik....4v 1
OWNER MAILING ADDRESS: 2_I CQc 38-71+ S
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OWNER PROPERTY ADDRESS: Q \ CA-1,1-iu („,,® P6
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TELEPHONE NUMBER OF CONTACT PERSON: L1 7 — 18)-2-
TAX
18)-2-
TAX MAP NO. : Section Block 3 Lot 3 a
CROSS STREET: 57-6Z (,/,‘,6 PC_�C
BUILDING PERMIT NUMBER CROSS REFERENCE:
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Sinature of Zicant
RECEIVED BY: aG
Town Jerk's Office
DATE: '- 3 - ?y
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