HomeMy WebLinkAboutKrueger ® Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY d FAX(5 16)765-1823
TOWN CLERK TELEPHONE(516)765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1153-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KRUEGER, MARJORIE H.
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Mailing Address 1 WEST SHORE AND OAK DRIVE
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Mailing Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Property Address 1 WEST SHORE AND OAK DRIVE
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 516-765-1178
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Tax Map No. section 80.00 block 1 lot 49.000
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Cross Street CORNER LOT
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Date Of Last Pump Out 0/00/00
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Issue Date: 6/15/89 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK F� _
Town of Southold 0��� y �lQG Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road c 7 Residential
P. 0. Box 1179 v' Non-Residential
Southold, New York 11971
Telephone '�lo,� Y►���
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /d
DATE G At 9/r?
OWNER NAME: M#+AdQRtF_ tf• tCR000,4-1.
OWNER MAILING ADDRESS: W135-r— SMOK12 A OAK- DR,
5O L
OWNER PROPERTY ADDRESS: S�¢M
OWNER TELEPHONE NUMBER: S/ G — 7 6,r ! '7�
TAX MAP NO. : Section g0, Block t Lot
CROSS STREET: Sr:ti rgiBOVE
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing
Residential r Non-Residential
DATE OF PREVIOUS PUMP-OUT:
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.)
' r
a
Signature of A plican
RECEIVED BY:
Town Clerk's Office
DATE:
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