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SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4424-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner THEMIS & MARIA KATRAKAZOL
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Mailing Address 1 98 STRATFORD AVE ,\
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Mailing Address 2
City St Zip GARDEN CITY NY 11530-0000
Property Address 1 305 PINE TERRACE
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Property Address 2
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City St Zip EAST MARION NY 11939-0000
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Owner Telephone No. 516-873-0421
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Tax Map No. section 22.00 block 5 lot 5.000
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Cross Street WILLOW DRIVE
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Issue Date: 11/03/10 Elizabeth A. Neville
-------- Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE �� �< Town Hall, 53095 Main Road
TOWN CLERK Cis P.O.Box 1179
REGISTRAR OF VITAL STATISTICS O Southold,New York 11971
MARRIAGE OFFICER 'fijJ • ��� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER Ol �a Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
11
Residential @$10 or Non-Residential @ $25 Application No. `�]
Permit No.
Owner Name V1 A Q J
Owner Mailing Address 446
C QTc - 3 v
Owner Property Address 30. 5 C&
Owner Telephone No. 6 —D
Tax Map No: Section ,0® Block Lot
Cross Street w L&) rj V,42-
Please check each that applies: New Construction
Alteration to Existing System
Residential Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
Signature of Applicant Date
Received by: