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I• Town Hall, 53095 Main Road
�y ®� � P.O. Box 1179
®l Southold, New York 11971
JUDITH T.TERRY ?%zzz%' FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1444-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MIRO, NICHOLAS J. AND FLORENCE
Mailing Address 1 P. O. BOX 619
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 495 KNOLLWOOD LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-8951
Tax Map No. section 107.00 block 6 lot 9.000
Cross Street GRAND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 4/20/90 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
is
OFFICE OF THE TOWN CLERK _ /��`
"'Town of Southold Q�-,FF�(�`," - 7 T
Off. Application No. 7
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road a :< 1 $10.00 - Residential
P. 0. Box 1179 Cr) #�� >;;z Y,
' ' � �. $25.00 - Non-Residential
Southold, New York 11971 O �
Telephone Q/ at
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
, OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE 11 //.—0V, iqgo
OWNER NAME: ]t 5 R E,U c I^- PlI R O
OWNER MAILING ADDRESS: BO. 160X 6 11
Nl111-TITU C K ' R1 L4 II`?5
OWNER PROPERTY ADDRESS: q� 1 !J0 14100 is P, Pk
W+y- 'T 1 TU c K w"4JLi . I 14/6"-
OWNER
qsOWNER TELEPHONE NUMBER: 516)- ,a q s--
TAX MAP NO. : Section' 1 01 Block (p Lot
CROSS STREET: Cr IS fi IUB /1 ilk--
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ' X New Existing 3<
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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:
Town- Clerk's Office
DATE:
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