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JUDITH T. TERRY a Town Hall, 53095 Main Road
TOWN CLERK P.O. Box 1 179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER - ® �' � Fax (516) 765-1823
'_ vN� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3038-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner CONSTATOURIS
Mailing Address 1 1675 MARLENE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1675 MARLENE LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-5178
Tax Map No. section 144.00 block 3 lot 8.000
Cross Street PECONIC BAY BLVD.
Date Of Last Pump Out 0/00/00
Issue Date: 6/04/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•
OFFICE OF THE TOWN CLERKc�vFFO(,(� =
Town of Southold 0�0 �G• , Application No.c902e
Judith T. Terry, Town Clerk
ote-
Town Hall, 53095 Main Road $10.00 - Residential
'> Vg`
P. O. Box 1179 Ens $25.00 - Non-Residential
Southold, New York 119714f '0� ���`�
40/- `a
Telephone _ Y► d
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10, 69
DATE irlajl 3092
OWNER NAME: TWOS S l lc- OUR-IS
OWNER MAILING ADDRESS: 169- Mankra
-S
010 'KVA 1\h/ RSca
OWNER PROPERTY ADDRESS: othet\
OWNER TELEPHONE NUMBER: ( SiQSt7ISZ
TAX MAP NO. : Section Block Lot 252
'CROSS STREET:
TYPE OF SYSTEM: '-Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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 iu
Town Clerk's Office
DATE::
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