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ELIZABETH A.NEVILLE Town Hall, 53095 Main Road
TOWN CLERK % o % P.O.Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS 1
MARRIAGE OFFICER `- 4,iL �.0 Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER �_'_Q1 jig #a®'i� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ,►�� southoldtown.northfork.net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
CONSTRUCTION OR ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. 3037 R Residential x Non-Residential
Fee $ 10.00 Septic X Cesspool
PERMIT ISSUED TO:
Name : FRANK KLOS
Address 1: 16645 MAIN ROAD
City St Zip MATTITUCK NY 11952
Descripton of Proposed construction or Alteration
ADDITION TO EXISTING SYSTEM.
APPROVED AS SUBMITTED. MAINTAIN REQUIRED SETBACKS FROM ADJACENT
WELLS, BUILDINGS, PROPERTY LINES AND WATER BODIES.
EXCAVATION INSPECTION REQUIRED. R10-03-0037
Name of Owner KLOS, FRANK
Mailing Address 1 16645 MAIN ROAD
City St Zip MATTITUCK NY 11952
Property Address 1 2300 GRATHWOHL ROAD
City St Zip NEW SUFFOLK NY 11956
Tax Map No. section 117.00 block 2 lot 12.000
Cross Street TUTHILL ROAD
Building Permit Number Cross Reference:
Issue Date: 6/11/03 Elizabeth A. Neville
southold Town Clerk
(TOWN SEAL)
,�oSUFFO��0;; 3037
ELIZABETH A.NEVILLE �����® oG�d 1 Town Hall, 53095 Main Road
1
TOWN CLERK ® P.O. Box 1179
y s Southold,New York 11971
REGISTRAR OF VITAL STATISTICS �' Fax(631) 765-6145
MARRIAGE OFFICER
7P,6 Fax
�1
�0®
RECORDS MANAGEMENT OFFICER =_"'/Qd Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ����iii southoldtown.northfork.net
17 am` Vj
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
TO: :.-Souiholdirowii Building Department
FROM: Linda J. Cooper, Southold Town Clerk's Office
DATED: May 8, 2003
Transmitted herewith is a copy of application No. 3161 for a Cesspool/Septic Tank Construction
Permit submitted by: ,
Frank Klos
Please review the application and location map and advise if the project has received Suffolk County
Health Department approval and if this office may issue the permit.
Please complete the form below and return it to me.
Linda J. Cooper
* * * * * * * * * * * *
I have reviewed the application and location map of the project cited above and make the following
recommendations:
APPROVE
DISAPPROVE
Comments: I .i
/ 1
71‘zrta.•? ' ‘c-4,
Signature
4 .5--7/3 0,3
Dated
-h
OFFICE OF IBE TOWN CLERK 'catf 0�y^ -
TOWNOFSOUTHOLD % % ` rl4Q•= Application No.3 1
ELIZABETH A.NEVILLE,TOWN CLERK If
•
P.O.BOX 1119 �+ Construction
SOUTHOLD,NEW YORK 11911 vT
q Alteration
Telephone ; P �Q�t' $10.00 - Residential
(516) 765-1801 --®1
• ,►��� $25.00 -Non-Residential
�iii/ilii
' TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
CONSTRUCTION or ALTERATION PERMIT
SEPTIC TANK or CESSPOOL
Permit No. .
Fee $
DATE m c t { aco
APPLICANT NAME: gran K --Klos
�
APPLICANT ADDRESS: /(p6 qSr a1 ar& T
f'l ayi- -y` of . NI I l QS 1 -
.. ,SEPTIC; ,x, ,
CESSPOOL! _
� \ - ,,. ,`tip°. -
DESCRIPTION OF PROPOSED CONSTRUCTION OR ALTERATION
.s , aA
LOCATION MAP: Must be attached hereto before permit may be issued.
LOCATION OF PROPOSED CONSTRUCTION OR ALTERATION':
OWNER OF PROPERTY: r-rar KIys
OWNER MAILING ADDRESS: / 6•61l6."' n)ca[A ?J
I`la K-riu,k. 11(4 /0sa
OWNER PROPERTY ADDRESS: . zoo l°,-roL-w)cJ 01, 1 'd
'lo Sa- 611c, 0 Ll ct
TELEPHONE NUMBER OF CONTACT PERSON: 63i _ ,gqk _ /pa3_:L O/_73gSon7.8
4-ymrsi TAX MAP NO. : Section • 11') Block Oo Lot 01a
CROSS STREET: - A
BUILDING PERMIT NUMBER CROSS REFERENCE: Q q ?y® 7 (c- )
()..4_64_,..._,L.- a_ _____
Signature of Applicant
_ o
RECEIVED BY• ;j
own lerk°s Office
DATE:
•
. . l\
I
- -
•--• CESSPOOL AT • /sem
ONd OESOUPI/OY
L ""'"• - ADJACENT PROPERTY I _ `'`� `.s`4 "`�'"•• 2/24/2003 • - °,•`•
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L // WWOE TO EASING WROVEVERs.PROTECr •PROVEIENTS AS ICCESSMY TO FACU1ATE NE• NWT/CATION
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(1 1 / /,- • ADJACENT PROPERTY Lf7 T4TO r OATWNED�Ri4WVE- ACRE REOUK0.
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I AND/ USES WELL L TER SUPPLY
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CESSPOOL AT • WATER N MOWN fME
ran° -�� Al04Kf
/ ADJACENT PROPERTY TO COARSE SAID SW /� - >-1WIM%I �I AS NOTED
. PB SW
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ADJACENT PROPERTY
W t5 20 25 -EniagCliiiEM ' imcooNea
TEST cc oN 24 �ANwRY zoosandonment of existing sanitary system A— O1
to be witnessed by HealthDepartment-
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