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B * Town Hall, 53095 Main Road
aY® t$ P.O. Box 1179
��° Southold, New York 11971
JUDITH T.TERRY `�.� ,,,0 ��� TELEPHONE
TOWN CLERK (516) 765-1801
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. 645-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner BELIS, GUS AND LUKAS
Mailing Address 1 15 INGRAM DRIVE
Mailing Address 2
City St Zip HICKSVILLE NY 11801-0000
Property Address 1 69700 MAIN ROAD
Property Address 2
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-931-2331
Tax Map No. section 45.00 block 5 lot 2. 000
Cross Street CHAPEL LANE
Date Of Last Pump Out 0/00/00
Issue Date: 3/08/88 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THETOWN CLERI""111. ` `''
Town of Southold Application
Judith T. Terry, Town Clerk ' '" `; /
Town Hall, 53095 Main Road c :°� 7 Residential �/
p. 0. Box 1179 cntreAti ; Non-Residential
Southold, New York 11971 O ® Ai: ** •
Telephone Y►�
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /AO
DATE 02%/gg
OWNER NAME: ,e/IS ` k,(1 -S
OWNER MAILING ADDRESS: /5- R Nin &lye.
11-/ 11Ji 71O7
OWNER PROPERTY ADDRESS: (0 9 700 r givi Road
G pc)v�F� n�, Y. i)9,49t
OWNER
i'-
OWNER TELEPHONE NUMBER: 516 - - a3)
TAX MAP NO. : Section f6 Block J Lot
CROSS STREET: CACtp L L-A n e-
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool V New Existing \/
Residential / Non-Residential
DATE OF PREVIOUS PUMP-OUT: 9-g7
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.)
.93-1AD 7dkr
Signature of Applicant
RECEIVED BY: '
Town Clerk's Office,
DATE:
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