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HomeMy WebLinkAboutSakarellos SCLfrHCLD WSTEVIATER d SPMAL PERM T CPERATI CN PERM T SEPTI C TANG or CESSPOCL Cper at i on Per ni t W. 4456-R Resi dent i al X Wn-Resi dent i al Fee $ 10. 00 New X Exi st i ng fSbrre Cf Owner ELI ZABETH SWFELLC6 ------------------------------ Nbi I i ng Address 1 P O BC}K 408 ------------------------------ Nbi I i ng Address 2 ------------------------------ CI t y St Zip GqEENPCRT W 11944-0000 -------------------- -- ---------- Property --------- Property Address 1 1375 V'ESTVCM LANE ------------------------------ Property ----------------------------- Property Address 2 ------------------------------ City ----------------------------- CIty St Zip C;EENPCRT W 11944-0000 -------------------- -- ---------- Ower Tel ephone W. 646-263-7889 Tax I*p W. sect i on 33. 00 block 2 1 of 3. 000 ------ --- ------ Cross St r eet SCLM DRI VE ------------------------------ ------------- -------------------- I --------------------------------------------------------------- I ssue Date: 6/27/ 13 8 i zabet h A Nevi I I e -------- Southol d Town a erk JOIN SEAL) P O��S�fFO�,�coG ELIZABETH A.NEVILLE C2 y� Town Hall, 53095 Main Road TOWN CLERK Z P.O. Box 1179 REGISTRAR OF VITAL STATISTICS D Southold, New York 11971 MARRIAGE OFFICER y • �� Fax(631) 765-6145 RECORDS MANAGEMENT OFFICER ��l �►aO 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 Residential @$10or Non-Residential @ $25 Application No. 12 Permit No. Owner Name e� A.�C_A a-g_�S Owner Mailing Address `P © '"O 8 Owner Property Address 1 (ADGS"_7LAjD0j_) 1. 4kC- 6 KUU POA:r N y k k-rj 14 g Owner Telephone No. b 4_(- �' �g E Tax Map No: Section Block ` Lot 3 Cross Street S00 0-D Dv2-t�C—' 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 fie t from system to building and closest road. New construction ma it cop of s ey th CHD approval.) Signa a'of Applicant Date Received by: