HomeMy WebLinkAboutKrudop, Kelly (2) •
ELIZABETH A. NEVILLE � Town Hall, 53095 Main Road
TOWN CLERK 4 P.O. Box 1179
REGISTRAR OF VITAL STATISTICS ; c.„
Southold, New York 11971
MARRIAGE OFFICER �b Fax (631) 765-6145
RECORDS MANAGEMENT OFFICER `!4CO
'M � ����� Telephone (631) 765-1800
FREEDOM OF INFORMATION OFFICER �U�I'+400 southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 4345-R Residential X Non-Residential
Fee $ 10.00 New X Existing
Name Of Owner KELLY KRUDOP
Mailing Address 1 4650 OLE JULE LANE
Mailing Address 2
City St Zip MATTITUCK NY 11952-0000
Property Address 1 50 TUTHILL LANE
Property Address 2
City St Zip CUTCHOGUE NY 11935-0000
Owner Telephone No. 631-298-7057
Tax Map No. section 96.00 block 1 lot 600
Cross Street COUNTY ROAD 48
Issue Date: 6/26/07 Elizabeth A. Neville
Southold Town Clerk
(TOWN SEAL)
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ELIZABETH A.NEVILLE ,t/, V Town Hall, 53095 Main Road
TOWN CLERK % p I P.O. Box 1179
REGISTRAR OF VITAL STATISTICS % W Southold, New York 11971
MARRIAGE OFFICER : el
'W �� Fax (631) 765-6145
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RECORDS MANAGEMENT OFFICER 0- ." Telephone(631) 765-1800
FREEDOM OF INFORMATION OFFICER 4/ �a��i 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.4 3y5
Permit No. a i3
Owner Name Klkett
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Owner Mailing Address � �
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Owner Property Address So Tvi4„11 lko l.Q,,r,L
GActr,s
Owner Telephone No. 63 - Zct g'!7c7
Tax Map No: Section Block °( Lot G
Cross Street CR 4`6 /
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 s ey with SC. I approval.)
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Signature of Applic. i .to
Received by:
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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
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S APPROYN_OF C,I)N7-;TRUCTPTI WORVS FOR
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Date MAY i 5 2007
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