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JUDITH T. TERRY Z
Town Hall, 53095 Main Road
TOWN CLERK v T P.O. Box 1179
REGISTRAR OF VITAL STATISTICSifs Southold, New York 11971
MARRIAGE OFFICER Q ®� .� Fax (516) 765-1823
10., �� Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2083-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KAMINSKY, JAMES AND CYNTHIA
Mailing Address 1 75 WOODCLIFF DRIVE -
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 75 WOODCLIFF DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4791
Tax Map No. section 107.00 block 7 lot 28.000
Cross Street BROWER ROAD
Date Of Last Pump Out 0/00/85
Issue Date: 3/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ����
Town of Southold �� Application No.
Judith T. Terry, Town Clerk :t •;„.‘.(4 %,I
Town Hall, 53095 Main Road ; $10.00 - Residential c..."
P. O. Box 1179 $25.00 - Non-Residential
Southold!„ New York 1/911 Owl ,<
Telephone
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(516} 16,5-1 Ol
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /p,
DATE /iza4-1 i '1l jqc�
OWNER NAME: miz. •f- AiRs • JA (1iEs grotliNsKY
OWNER MAILING ADDRESS:
OWNER- PROPERT' ADDRESS: PfS 0-1! R, .
T
MATT ILN
) C.' KI y II0I S�
OWNER TELEPHONE NUMBER: ( I(o) 9 'R.- tog 1
TAX MAP NO. : Section I 0 11 Block, Lot c, 8
CROSS STREET:
TYPE;OF,-SYSTEM: -Septic Tank - - ---New Existing
Cesspool New Existing
Residential V Non-Residential
DATE OF PREVIOUS PUMP-OUT: d 9 $• 5
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.)
__...1 A. JILL
0 Signature of A.plicant
RECEIVED BY: _
Town Clerk's Office - - •- - - '
DAT E: - -
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