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JUDITH T. TERRY ,. Town Hall, 53095 Main Road
TOWN CLERK : toP.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER r=" ,'!. Fax (516) 765-1823
_��®l ��®/�! 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. 1901-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KOHN, DANIEL N. AND WIFE
Mailing Address 1 RD 1, 500 LITTLE PECONIC ROAD
Mailing Address 2
City St Zip CUTCHOGUE NY 11935-0000
Property Address 1 500 LITTLE PECONIC ROAD
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 516-734-5561
Tax Map No. section 111 .00 block 14 lot 12.000
Cross Street VANSTON ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 5/15/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
' a Orn
OFFICE OF THE TOWN CLERK ' cOFO(,r.'- f
Town of Southold. V� , CQG' Application No. / 701
Judith T. Terry, Town Clerk �� c.i
Town Hall, 53095 Main Road . _ -< 1 $10.00'- Residential,
p. O. Box 1179 tri `, .-` «. .�`' $25.00 - Non-Residential
Southold, New York 11971 O �t•
Telephone *ei 0 '
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION" PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE J77/(7/9?/
•
OWNER NAME: 7,,/ JYM CJ , '
OWNER MAILING ADDRESS: IF, D ri I 5 6•a „tia.-,C ,
OWNER PROPERTY -ADDRESS: R j' -”6.-0 U .. �.. ,_ ...� CW -l.,
OWNER TELEPHONE NUMBER: '73q _ rr,3 '4 ) a
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TAX MAP NO. : Section / Block ( Lot
CROSS STREET: ! e2/,-7,2.-0--/, -
TYPE OFSYSTEM: Septic Tank r, , New Existing „/__
Cesspool /
' �/ New Existing 1/ - '
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: '
LOCATION MAP: Must be attached hereto before permit may be issued. i,. ,
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
/41
Signature of Applicant
RECEIVED BY:: •` '1 - -
.Town C, erk's Office .
DATE: - ',4) /l �-2--
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