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ELIZABETH A.NEVILLE,RMC,CMC O Town Hall, 53095 Main Road
TOWN CLERK l P.O. Box 1179
REGISTRAR,OF VITAL STATISTICS' Southold, New York 11971
MARRIAGE OFFICER • �O� Fax(631) 765-6145
RECORDS MANAGEMENT OFFICEROl Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER ycou m� southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
So=OLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4394-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner PAUL PAWLOSKI & CRAIG CORNELL
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Mailing Address 1 214 WEST 29TH STREET 'S uk-gA d
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Mailing Address 2 APT 6E }�{1�Y1S
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City St Zip NEW-YORK NY 10011-0000 in c
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Property Address 1 13455 MAIN BAYVIEW ROAD o e
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Property Address 2
City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 631-445-4348
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Tax Map No. section' 88.00 block ' 2 lot 15.000
Cross Street
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Issue Date: 6/15/09 Elizabeth A. Neville
- -------- Southold Town Clerk
(TOWN SEAL) .
_,,06/08/2009 06:11 6312980901 PECONIC BAY MATERIAL PAGE 01
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U TJk site rhm1op2ment, n4c.
dba Peconic Bay Materials
260 Cox Nea Road
Mattituck, NY 11952
Phone 6-31-298,0900 X11®31-831-8786 Fax 631-298-0901
CERTIFICATION OF SEWAGE DISPOSAL. SYSTEM BY INSTALLER
Health Department Reference Number: IQ I o r 00 0"7
Suffolk Tax Map# Dist- - Sect(s)__ Slk(s)-_
Project Name or Address.-
Subdivision
ddress:Subdivision Name&Lot#
Applicant's Naim;
Description of System Installed.
Septic'Tank
Volume (gallons)._/910 _
Shape Q Rectangulariylindrical
Name of precast Markuffacturex: Cu/ j K
Leaching Pools - --
Numt*,r of Pools
Dtarneter and Depth
Name of Precast Mfanufacturer-
Other:
Attach a sketch below the rneaSurements from building corners to the access covers of disposal system.
1. s"
-2
. A
36 �
I hereby certify that the subsurface sewage disposal systean, described herein, has been installed by we in
accordance with the approved plaAs aatd 6tandards of the Suffolk County Department of health Services,
and is operational.
Installer Signature: pate:
Print Name/Comp Y
Phone:
Consumer Affairs License Number:_ Y z
o�Og�fFO�,�co ,
ELIZABETH A.NEVILLE �`t` �y Town Hall, 53095 Main Road
TOWN CLERK p P.O. Box 1179
H 2 Southold, New York 11971
REGISTRAR OF VITAL STATISTICS W_ A�
MARRIAGE OFFICER Oy �.�` Fax(631) 765.6145
RECORDS MANAGEMENT OFFICER O Telephone (631) 765-1800
FREEDOM,OF INFORMATION OFFICER O'� �a southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @ $10 or Non-Residential @$25 Application No. 3 9 y
Permit No. ' <(9
Owner Name
Owner Mailing Address
Owner Property Address pA�
Owner Telephone No.
Tax Map No: Section Q&V Block R'Sf' Lot 2 '�
Cross Street ,.c Citi•/
Please check each that applies: New Construction
Alteration to Existing System
Residential. Non-Residential
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. (Locate
building and system; give north arrow and approximate distance in feet from system to building
and closest road. New construction may submit copy of survey with SCHD approval.)
4if
ature of Applic ate
Received by: