HomeMy WebLinkAboutKaminsky (2) A
_,
tr ,oil OFFOUr
G
JUDITH T.TERRY tt �'.A : Town Hall, 53095 Main Road
TOWN CLERK ; P.O. Box 1179
REGISTRAR OF VITAL STATISTICS �`® Southold,New York 11971
� Fax(516) 765-1823
MARRIAGE OFFICER :�** ®���
RECORDS MANAGEMENT OFFICER 0,1 i„%0.11 Telephone(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. 161-N Residential Non-Residential X
Fee $ 25.00 New Existing X
Name Of Owner KAMINSKY, CYNTHIA
Mailing Address 1 75 WOODCLIFF DRIVE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 80 EAST MILL ROAD
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4791
Tax Map No. section 106.00 block 4 lot 3.000
Cross Street GRAND AVENUE
Issue Date: 9/19/96 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
F ,
S 1/0.
OFFICE OF THE TOWN CLERK ��FOLt#"-
Town of Southold4 ) •
, M �Q��1 Appli catior /6/
Judith T. Terry, Town Clerk . •
"* $10.00 - Residential
Town Hall, 53095 Main Road c� 5 ° .r ---
M 3 Ott
w QRS„✓.�Y� 't�'T`
P. 0. Box 1179 , �� ,������ ��' $25.00 - Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801 rn
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE 4716
OWNER NAME: @,‘i NMI A, KlArtiti IVB SK Y
OWNER MAILING ADDRESS: , : ,? .1 ' .
17L6Uti6TAA. Z Ary 1_l,5�
OWNER PROPERTY ADDRESS : 218 EAST- /'1 i C._L
OWNER TELEPHONE NUMBER: oC `_9.1
TAX MAP NO. : Section Block Lot .
1. n
CROSS STREET: rd •
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool K' New Existing d�
Residential Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued. (6r12)t)
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
• J
Signature of Applicant /'
RECEIVED BY:
Town Clerk's Office
DATE: '
•
-
R
IvA
IA,5
, A
100
IA/