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JUDITH T. TERRY ; Z : Town Hall, 53095 Main Road
TOWN CLERK T P.O. Box 1179
REGISTRAR OF VITAL STATISTICS Southold, New York 11971
MARRIAGE OFFICER yQ �. Fax (516) 765-1823
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(516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 3121-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KRAUS, ROBERT E.
Mailing Address 1 95 KENILWORTH DRIVE WEST
Mailing Address 2
City St Zip STAMFORD CT 06902-0000
Property Address 1 4200 YOUNGS AVENUE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 203-324-4682
Tax Map No. section 55.00 block 2 lot 13.000
Cross Street NORTH ROAD
Date Of Last Pump Out 0/00/90
Issue Date: 9/23/93 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
•• • ...
OFFICE OF THE TOWN CLERK ,��F�FU ��. )��
Town of Southold �� -� GQG'; Application No.
Judith T. Terry, Town Clerk . �' -' y
Town Hall,
53095 Main Road �` jr $10.00 - Residential
ic
P. O. Box 1179 cr3 7. f:4, :; - Z $25.00 - Non-Residential
Southold, New York 11971 u.O ® . ,
Telephone 141e1.40-"
(516) 765-1801
TOWN OF SOUTHOLD _
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK orr 'CESSPOOL
Operation Permit No. .
Fee $
DATE
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OWNER NAME: � • � /�
OWNER MAILING. ADDRESS: /� [M. I\ ,c.v X) f'_.. i '
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OWNER- PROPERTY- ADDRESS: 2 ' O -2) ,-71-1, A-71.(-, 011--v-
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OWNER TELEPHONE NUMBER: Z D 3 z Y 9
TAX MAP NO. : Section 1/454-J Block 2_ Lot 1 _3
CROSS -STREET: AL
teL
TYPE OF SYSTEM:_-,_ Septic Tank ---- -- New Existing
Cesspool l� New Existing
Residential r/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: t. 9 9 6
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.)
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Signature of Applicant
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RECEIVED BY: co _'�. _ _ _ _. , _ _ , . . .
-
. - - - , . Town erk s Office
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DATE: , - gig23
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