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JUDITH T.TERRY ® =µ;¢N Town Hall,53095 Main Road
TOWN CLERK ; eiD <�' g P.O.Box 1179
y.' Southold,New York 11971
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER \ ,'f l* / Fax(516)765-1823
RECORDS MANAGEMENT OFFICER = CI Vosii$ Telephone(516)765-1800
FREEDOM OF INFORMATION OFFICER ,,•"e
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3353-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner ANDREJACK, THOMAS
Mailing Address 1 855 KNOLLWOOD LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 855 KNOLLWOOD LANE
Property Address 2
City St Zip MATTITUCK NY 11952-0000
Owner Telephone No. 516-298-1994
Tax Map No. section 107.00 block 6 lot 5.000
Cross Street GRAND AVENUE
Issue Date: 6/13/95 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'! OFFICE OF THE TOWN CLERK icvFFOC,(-�'-
Town of Southold , 0�� CQ• G ,, Application No.
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road 8 ° - . $10.00 - Residential
P. O. Box 1179 to hi ' $25.00 - Non-Residential
Southold, New York 11971 O *-$
Telephone /0 * 'NO•
(516) 765-1801
TOWN OF SOUTHOLD
•
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
,
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
•
DATE 03/9.5—
.
OWNER NAME: / / fvr�s 4i)xesAck
OWNER MAILING ADDRESS: 55-5 e,✓c tie,)odd (4_
fflI4 r7 Tr/Ci ^2/ // 5")
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7.1 r/1%7
TAX MAP NO. : Section /6 7 Block Lot 5—
CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Vg
Cesspool New Existing
Residential Non-Residential
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 Applica'
RECEIVED BY: v''f
Town Clerk's Office r.
DATE: ' / FSS
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