HomeMy WebLinkAboutKrupski ELIZABETH A.NEVILLE '$1 �� Town Hall, 53095 Main Road
TOWN CLERK ® ; P.O. Box 1179
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Southold, New York 11971
REGISTRAR OF VITAL STATISTICS ® 1
MARRIAGE OFFICER :� ����1' Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER =,,®1 ��'C �I� Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER �s'
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4013-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner KRUPSKI, RAYMOND & CECELIA
Mailing Address 1 P. O. BOX 1772
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 13780 SOUNDVIEW AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-5618
Tax Map No. section 540.00 block 3 lot 4.000
Cross Street HORTON'S LANE
Issue Date: 2/25/00 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK ' �FFO /"
TOWN OF SOUTHOLD 0� 5 COG Application No.
._2 .-3
FI.I7,ABETH A.NEVILLE,TOWN CLERK $10.00 - Residential
P.O.BOX 1179
SOUTHOLD,NEWYORK11971 �1J $25.00 - Non-Residential
-- Telephone _OI •11
(516) 765-1801 '
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERAT ION PERMIT '
SEPTIC TANK or CESSPOOL
Operation Permit No. /2
Fee $ (0, 00
DATE a/./ 6(00
OWNER NAME: si"1-Y ACovvo e6:6.rw 76P_Gr,o 57C I.
OWNER MAILING ADDRESS: /JO ,50 )< (777
cr Q7/1-o L, Ny // ' 7/
OWNER PROPERTY ADDRESS: (37 ?o rocc/t/Jw/ R}t/.c,'✓etez
S'acc-7z 0�, /1/, //P7/
OWNER TELEPHONE NUMBER: .. 16 - 76 S= 5-6 /y
TAX MAP NO. : Section 5 'j, oo Block 3 Lot Y. 00.=,
CROSS STREET: (-/o,era'/!' GAN/
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential f 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 Applicant
RECEIVED BY: 1/ 4-- e/
Tow Clerk's Office
DATE:
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