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JUDITH T.TERRY �� � $fit;\ Town Hall, 53095 Main Road
TOWN CLERK Z P.O. Box 1179
4 Pry; Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER \* 0.00 Fax(516) 765-1823
RECORDS MANAGEMENT OFFICER : a/ Jit S00,06Telephone(516) 765-1800
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3701-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KLOS, THOMAS A.
Mailing Address 1 P. O. BOX 771
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 1235 JOCKEY CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5401 lg` ®/3
Tax Map No. section 70.00 block ---2 lot /69/1(07C7 69/ /�J/� C7
Cross Street GILBERT
Issue Date: 10/14/97 Judith T. Terry
. Southold Town Clerk
(TOWN SEAL)
OFFICE' OF THE TOWN CLERK c.VFFO(,(��
Town t�f Southold �� CQIj= Application No. ' 1
Judith T. Terry, Town Clerk .�
Town Hall, 53095 Main Road +�= � $10.00 - Residential
P. O. Box 1179 tri HeY,. � �rtii �`` $25.00 - Non-Residential
Southold, New York 11971 4Y-
*.7
Telephone o.( ,i 'N
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 10 SOD
DATE / 0 —9--C1-1
OWNER NAME: O ,Q1A
OWNER MAILING ADDRESS: O aBD 11
OWNER PROPERTY ADDRESS : ,3 _ C� vie
OWNER TELEPHONE NUMBER: 1- 65
TAX MAP NO. : Section /00 0 Block '70 . Lot c /9, / 3
CROSS STREET: G\ \ t
TYPE OF SYSTEM: Septic Tank. '' New Existing
Cesspool New Existing
Residential Non-Residential •
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.)
<Z
011.6 1 A
-= •
f ' Signatur of Applicant
RECEIVED BY:
Town Clerk's Office RECEIVED
DATE: OCT 14 1997
Southold Town Cisrk
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SURVEY FOR
THOMAS A.KLOS 8 ROSEMARY E KLOS
FEB. 21,1985
AT SOUTHOLD DATE JUNE 18,1980
TOWN OF SOUTHOLD SCALE 1":00• ,
SUFFOLK COUNTY, NEW YORK No. 80-336
N UIIAuTNONIEtO ION OR ADDITION TO Thu GUARANTEED • OF NfN, I
s URVET 6 a T1124.ATIDN OF SECTION 7109 OF THE
NEW VOR(STATE EDUCATION LAW USLIFE TIT NSSt� Q W YORK
*COPIES ff THIS SONNET NOT SEARING TME LAND THOMAS A Lb 41108614 E. OS
IURvEIVA's INKED SEAL OR EW3OISED SEAL SMALL SOUTHOL S All S BANK%
MOT 9t CONSIDERED TO OE A NA LID TRUE COPT �.
!Gm ANANTEES INDICATED HEREON SHALL RUM ONLY TO j• dial'
HEALTH DEPARTMENT-DATA fOR APVROVAL TO CONSTRUCT TME PERSON PON INNOM THE suavET IS PREPARED * u 6 I.
/NO HIs DEMALF TO THE TITLEGCOMPANY,LISTED- !' .t41 411
IT NEAREST A A RAIN MI : ASOUNCC OF NATla-PR11NT[ PUSLIC_ MENTAL &GENET AMD LENDING INSTITUTION ,t....
P SIIF CO TAA MAP DIST M00 SECTION OTO *LOCK 2 LOT O 19.6 HFREON,AND TO TME ASSIGNEES OF TME LENDING 6-
RTHEIR ARE NO DWELLING( WITHIN 100 FEET OF THIS*ROPENTT INSTITUTION GUARANTEES ARE NOT TRANSTENADLE i
OTHER THAM THOSE SMO>•N HEREON 70 ADDITIONAL, tNSTTTUTIONS 0/9 SU*S.oyF*T