HomeMy WebLinkAboutKlos JUDITH T. TERRY � Town Hall, 53095 Main Road
TOWN CLERK •
T • P.O. Box 1179
REGISTRAR OF VITAL STATISTICS � Southold, New York 11971
MARRIAGE OFFICER Fax 0� ��, Fax (516) 765-1823
',y®1 .11b ,"" Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 2048-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KLOS, ROBERT
Mailing Address 1 1010 DONNA DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 1010 DONNA DRIVE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9166
Tax Map No. section 115.00 block 15 lot 17.000
Cross Street NEW SUFFOLK AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 2/22/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK •cOFO(,r �6 �?
Town of Southold ��
i--
QG' Application No.
Judith T. Terry, Town Clerk ` , yts $10.00 - Residential
Town Hall, 53095 Main Road o
P. O. Box 1179cn $25.00 - Non-Residential
Southold, New York 11971 Off®
Telephone ( �► •
��
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE ® '93
OWNER NAME: ,l5749®e f"-fol
OWNER MAILING ADDRESS: /a / 60 i) /Vfl J7/€.
�� - OWNER PROPERTY-ADDRESS: --__ _ _ _.
OWNER TELEPHONE NUMBER: ,,a2 -- 9/4.
TAX MAP NO. : - Section . / -,( Block /3 Lot /
CROSS STREET: -->jc-7Yelfr-e1/4"-
,
TYPE OF SYSTEM: Septic Tank „/ _New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: fitb7— P,€i.e-
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.)
_
Signature of Applicant
RECEIVED BY: _ (/"
own Cle k's, Office
DATE: 3 �)
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