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Town Hall, 53095 Main Road
P.O. Box 1179
® Southold, New York 11971
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JUDITH T.TERRY .Cn %40' FAX(516)765-1823
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TELEPHONE(516)765-1801
TOWN CLERK
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. 1316-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner APODIACOS, ERAKLIS
Mailing Address 1 7122 RIDGE BLVD.
Mailing Address 2
City St Zip BROOKLYN NY 11209-0000
Property Address 1 217 NORTH ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 718-833-5563
Tax Map No. section 35 block 5 lot 3
Cross Street COSTELLO ROAD
Date Of Last Pump Out 0/19/85
Issue Date: 11/28/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 'c0FO(,1, = _
Town of Southold Q Y C'
� � ��G Application No.
Judith T. Terry, Town Clerk ate y
x w °� f= �G $10.00 - Residential
Town Hall, 53095 Main Road .H x -
P. O. Box 1179 cry ti $25.00 - Non-Residential
Southold, New York 11971 04:::5
Telephone ®! llfg ft�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /V / /7rq
OWNER NAME: w7,fico.c- , ztv l l S •
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OWNER MAILING ADDRESS:
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OWNER PROPERLY_ ADDRESS:
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OWNER TELEPHONE NUMBER: b''336?
TAX MAP NO. : Section j � Block Lot
CROSS STREET: � P�� /Per-Y(,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: /4 Ts--
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 pplicant
RECEIVED BY: ! 1 /LA-hiuP
Town Clerk's Office
DATE: // / V
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