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JUDITH T. TERRY ; 1. Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS 1 Southold, New York 11971
MARRIAGE OFFICER = ® - � Fax (516) 765-1823
=__�,yol '.) b .' Telephone (516) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3084-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner BROWN, CLEMENT AND PATRICIA
Mailing Address 1 345 KNOLLWOOD LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 345 KNOLLWOOD LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-4119
Tax Map No. section 107.00 block 6 lot 10.000
Cross Street GRAND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 8/10/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
,,
OF 'E OF THE TOWN CLERK COMA'
Town of Southold &% -:� _ CQG•` Application No. 3 o?V
Judith T. Terry, Town Clerk .:.: e',, k; y --------
Town
/
Town Hall, 53095 Main Road
<.ti... T �C 7 $10.00 - Residential
P. O. Box 1179 tri s=ue 'f'==r=:- i ` $25.00 - Non-Residential
Southold, New York 11971 O ��`
Telephone .( Y1 '.
(516) 765-1801 /
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /0, 0 0
DATE <9 - 6 - ?._.?
. .
OWNER NAME: eJ.d.MGN r $ l A.r'2Ic ;4- lJ evw,/
OWNER MAILING ADDRESS: 3%..(716vo /lwo j a! L•9•L/�
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OWNER PROPERTY ADDRESS: --- /
se,4•e_. /d'•c A ev4-
OWNER TELEPHONE NUMBER: j '1 - f?- V//9 }
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TAX MAP NO. : Section • JO 7 Block (, Lot /D
CROSS STREET: g i,g-,✓ d /9v-t..
TYPE OF SYSTEM: Septic Tank New Existing v
•
Cesspool New Existing '*-- --
Residential
Residential 'V Non-Residential
DATE OF PREVIOUS PUMP-OUT: / -/ze /993
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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Signature of Applicant
RECEIVED BY: .
/c, own Clerk's Office
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DATE: - 0 ! 7r,3
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