HomeMy WebLinkAboutKrudop, Robert (2) o
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ELIZABETH A.NEVILLE �0'~ .# I Town Hall, 53095 Main Road
TOWN CLERK 2 Z P.O.Box 1179
REGISTRAR OF VITAL STATISTICS �.O � Southold, New York 11971
MARRIAGE OFFICER "-..WA a0lei Fax(631) 765-6145
RECORDS MANAGEMENT OFFICER _ 1 * �► ,oi' Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER -
•....,.•'' southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
OPERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 j or Non-Residential @$25 Application No. `? Z
Permit No.
Owner Name
Owner Mailing Address ZcO Oie_SJa L .
►M 41.1-k 1 /i4cz
Owner Property Address IfC(Tv < - 5 L- L--
i i f 4 - �X it'isz
Owner Telephone No. 251.6-'74--
Tax
1$-'7STax Map No: Section 1'27.- Block Lot �L('
Cross Street S _ /
Please check each that applies: New Construction
Alteration to Ex7ig 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 survey t ► 111 approval.)
Cfr5".
Sign. e of Applicant D e
Received by:
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
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APPROVAL OF 00!•: -:"i7JC;7:7F.D WORKS FOR ?I deq-,,,,,
A SiKf.:',:•LE F-.1-,',=;;i2!'" --:":::::;I:rIN:::•Z-.^ .
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' Date APR L9_2005 11,C. F:;,-. ",;* :,.iSi 0'04-0).3) 0. ."-•Lam % "
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Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 04/26/05 Receipt#: 2641
Transaction(s): Reference Subtotal
1 1 Septic Permit-Operation - Resid. 4282 $10.00
Check#: 2641 Total Paid: $10.00
Name: Krudop, Kelly& Robert
4650 Ole Jule Ln
Mattituck, NY 11952
Clerk ID: LINDAC Internal ID:4282