HomeMy WebLinkAboutBaktidy OFFICE OF THE TOWN CLERK • FOCil/
Town of Southold %`"
Judith T. Terry, Town Clerk ' f• : % x �
Town Hall 53095 Main Road
P. 0. Box 1179 A� ``ft` �
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Southold, New York. 11971-
Telephone '1 1
(516) 765-1801 -
TOWN OF SOUTHOLD'
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 450 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: ' Theofani Baktidy
- OWNER MAILING ADDRESS: 147-37 20th Avenue
Whitestone, New York 11357
OWNER PROPERTY ADDRESS: 2710 Westphalia Road
Mattituck, New York
OWNER TELEPHONE NUMBER: 718-746-8654
TAX MAP NO. : Section , 114 Block 7 Lot 6
CROSS STREET: Deer Drive
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
- Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
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Judith T. T rry
Southold Town Clerk
DATE: September 30, 1987
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(TOWN SEAL)
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OFFICE OF THE TOWN CLERK .c31Fair
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Town of Southold �� ;a _ CQG Application No. C/)
Judith T. Terry, Town Clerk b'
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Town Hall, 53095 Main Road c �;?�z Residential
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P. O. Box 1179 cn "
�- `'` � moi ' Non-Residential
Southold, New York 11971
Telephone _ .(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. Z-M7)
Fee $ f6
DATE
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OWNER NAME: ii.f;t1)Mg/ 9k/G
OWNER MAILING ADDRESS: /t _ 3 7 o?,U1"°
OWNER PROPERTY ADDRESS: !i7 f0 z./.847 A ,GfG4�'
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OWNER
/0(c -OWNER TELEPHONE NUMBER: I/, C /kg - orti
TAX MAP NO. : Section //� Block 7 Lot 6
CROSS STREET: 8 / 7 1"�ri��/� ge2a1 /ed4 at) /U �-c
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U�TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential j/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7,(4, 4,,L,,
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.)
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Signature of pplicant
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RECEIVED BY: • /%�
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n C'erk s 7 fice
DATE: 7/a°/A>
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