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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK p i
P.O. Box 1179
t Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ��� Fax 516
MARRIAGE OFFICER � . ( ) 765-1823
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�® �! 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. 1967-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COMM!NS, PATRICK
Mailing Address 1 350 KNOLLWOOD LANE
Mailing Address 2
City St Zip MATTTIUCK NY 11952-0000
Property Address 1 350 KNOLLWOOD LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-9356
Tax Map No. section 107.00 block 1 lot 19.000
Cross Street GRAND AVENUE
Date Of Last Pump Out 0/00/00
Issue Date: 9/10/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK c3IFO(,r
Town of Southold . ,-
% ,. CQG•; Application No. `7 7
Judith T. Terry, Town Clerk % '
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Town Hall, 53095 Main Road S- .v : -�I $10.00 - Residential
p. O. Box 1179 to -•‘. ��a - ;' $25.00 - Non-Residential
Southold, New York 11971 O2® '10 *'�$
Telephone _Oj ��
(516) 765-1801
RECEI TOWN OF SOUTHOLD
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SEP 1 9 199? SOUTHOLD WASTEWATER DISPOSAL DISTRICT
'own Cterii Southold_
APPLICATION
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4111,9)
�'1Y�,�+; OPERATION PERMIT
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SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ 100-0
DATE R- ,7-9L
OWNER NAME: (Pi4c:=CtRACA CO a 1 SNI I S
OWNER MAILING ADDRESS: 5O Vkn®LLkAi®®6( L4-11 -C,
VM 11- ---k- 1T-0 CX kec,t,yoliX d 19 Yi -
OWNER PROPERTY ADDRESS: 214-01 E
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OWNER TELEPHONE NUMBER: Ks,— a,'I &9 3-slo
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TAX MAP NO. : Section 101 Block 1 Lot 19
CROSS STREET: C:RtAvub V--
TYPE OF SYSTEM: ' Septic Tank New Existing
Cesspool K New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: uKVI, eft&i* VW, A.Agifuc Iu`R‘�oiiki
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.)
1111,- f Co--InPL.-1-----1-1--,1 .
Signature of Applicant
RECEIVED BY: -
Town Clerk's Office
DATE: •
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