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u' T; Town Hall, 53095 Main Road
O� � P.O.I �� Box 1179
Wa; ill Southold, New York 11971
JUDITH T. TERRY 4."1•ArAre 04°',ITELEPHONE
TOWN CLERK (516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1070-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KLOS, THOMAS
Mailing Address 1 P.O. BOX 771
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 SCHOOLHOUSE ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-765-5401
Tax Map No. section 102.00 block 5 lot 10.000
Cross Street NORTH STREET
Date Of Last Pump Out 0/00/00
Issue Date: 4/05/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
.
OFFICE OF THE TOWN CLERK .SWMi.�'=
Town of Southold �:t-�C�G� Application No.
/0925
Judith T. Terry, Town Clerk . 0 ,- %7 :A y
~ "=• *I's� ;1 �C 1 Residential
Town Hall, 53095 Main Road 1.7
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cn 7' ;- 4.
P. O. Box 1179 ,-r� ; Non-Residential
Southold, New York 11971 0.O � 0��.
Telephone '__i * 1►
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
.�e � ,, APPLICATION
MAR 0 81989 for
r OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $/0 LOD a
DATE-,3 - e3,9
OWNER NAME: I I' 10 M \\os
OWNER MAILING ADDRESS: .0 . IBO) f I
Cu- r .00 G u i iQ Y S fl3c"
OWNER PROPERTY ADDRESS: OOO -. 1-{OvL . ,1
___C..,STCH OGIDL y tg3
OWNER TELEPHONE NUMBER:, 725 - `j CD ( {
TAX MAP NO. : Section 173-q- 19 13 Block Lot -
CROSS STREET: \oQ l- Et✓7
TYPE OF SYSTEM: Septic Tank_0- New Existing _
Cesspool X New Existing
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: q/a
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.)
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RECEIVED BY: 64g-r
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. DATE: • SPR 451969
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SUtZV1sY' `P,CL•1:P'QILED • JUNE !6 , 1969
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TITLE N? d-7. 49910 - • _ - GQl CNPOk.T ,' 1 \V YOILV. ,