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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK ® T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Ls” Southold, New York 11971
MARRIAGE OFFICER �. Fax (516) 765-1823
t - �® ��� 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. 1629-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KLOS, THEODORE
Mailing Address 1 475 AKERLY POND LANE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 475 AKERLY POND LANE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-2152
Tax Map No. section 69.00 block 5 lot 11 .001
Cross Street MAIN ROAD
Date Of Last Pump Out 0/00/86
Issue Date: 2/21/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK 0, ...at. / 6-•,:=2 Town of Southold �Q C� Application No. l
Judith T. Terry, Town Clerk y0
' ` � :.� ��� '� 10.00 - Residential
Town Hall, 53095 Main Road . o• - $
O. Box 1179 " s;y,-,•
•P. �' �-•� „�-r.'-;��� �� $25.00 - Non-Residential
Southold, New York 11971 O ''�0 ��`
Telephone 1 JJ(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE '�.C/U', e J „f
OWNER NAME: �Htd po RE k LGS •
OWNER MAILING ADDRESS: y` ..5- /cE/ 1—y (a ,v i L�
5o ut c, O l A.,y 11 971
OWNER PROPERTY ADDRESS: y��A/rt-ALv (° ,v J L N
5Ou -c7 t d, ij 11672l
OWNER TELEPHONE NUMBER: 76.3=
TAX MAP NO. : Section (p 67 Block Lot 1// /
CROSS STREET: / ISI t Ai
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool - New Existing )(
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: j?54
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:
T 'l n Clerk's Office
DATE: /-1-( / ‘ /
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