HomeMy WebLinkAboutKruk OFFICE OF THE TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179
Southold, New York 11971 O O�
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 142_- Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Edward and Lydia Kruk
OWNER MAILING ADDRESS: 9625 Main Bayview Road
Southold, New York 111971
OWNER PROPERTY ADDRESS: 9625 Main Bavview Road
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-5148
TAX MAP NO. : Section 88 Block 3 Lot 23,1
CROSS STREET: Victoria Drive
TYPE OF SYST-EM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: August 18, 1986
Judith T. Terry
Southold Town Clerk
DATE: November 13, 1986
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�sFF�(�(
Town of Southold 0�� CQG Application No. AM
Judith T. Terry, Town Clerk S
Town Hall, 53095 Main Road c -� �, Residential
P. 0. Box 1179 '3 :+ Non-Residential
Southold, New York 11971 O
Telephoneo.(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. �G��✓
Fee $ /o
DATE F4
OWNER NAME:
OWNER MAILING ADDRESS: ,94,95
OWNER PROPERTY ADDRESS: 9,46Z5 /8?f�s.+/G�At✓�/a /r.�
OWNER TELEPHONE NUMBER: 76 5 -
1 ?E, -' 3
TAX MAP NO. : Section Block Lot
CROSS STREET:�/r
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool r/ New ,, Existing �A
Residential ;� Non-Residential
DATE OF PREVIOUS PUMP-OUT:. ���(
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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:
p Q own Clerk'g Office
DATE:- ,fa06�1111p �
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