HomeMy WebLinkAboutKrukowski OFFICE OF THE TOWN CLERK � �
Town of Southold OQ5 Cly
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179
Southold, New York 11971 Q ® O�-
Telephone �(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
- OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 268 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER: Lillian Krukowski
OWNER MAILING ADDRESS: Main Road, RFD #20
Southold, New York 11971
OWNER PROPERTY ADDRESS: Main Road
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-3111
TAX MAP NO. : Section 55 Block 6 Lot 34
CROSS STREET: Laurel Lane
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: December 20, 1986
Judith T. Terr
Southold Town Clerk
DATE: April 13, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold ��� CQG Application No.
Judith T. Terry, Town Clerk Y -
Town Hall, 53095 Main Road :`L Residential
P. O. Box 1179 U13 ,¢ ;F Non-Residential
Southold, New York 11971 O
Telephone(
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
fCr
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE
OWNER NAME:
OWNER MAILING ADDRESS: j�, °y ,
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER:
cJ�
TAX MAP NO. : Section 9 / Block Lot
01i� CROSS STREET:
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential _Non-Residential
DATE OF PREVIOUS PUMP-OUT: 2pZ84
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.)
a � `
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Signature of Applicant
RECEIVED BY:
Town Clerk's Office
DATE:
LAS
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