HomeMy WebLinkAboutKrukowski (2) OFFICE OF THE- TOWN CLERK
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road c
P. 0. Box 1179 ' cn
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 546 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Margaret Krukowski
OWNER MAILING ADDRESS: Boisseau Avenue
Southold New York
OWNER PROPERTY ADDRESS: Boisseau Avenue
Southold, New York
OWNER TELEPHONE NUMBER: 516-765-3146
TAX MAP NO. : Section 55 Block, 6 - Lot qq
CROSS STREET: County Road 48
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Unknown
Judith T. T&Crry
Southold Town Clerk
DATE: December 21 , 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK
Town of Southold �® �Q� Application No.115q
Judith T. Terry, Town Clerk <°'. n }
Residential
Town Hall, 53095 Main Road
P. 0. Box 1179 v� Non-Residential
Southold, New York 11971
Telephone
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ (�
DATE ! `/ 7r
OWNER NAME: J R C / R ('
OWNER MAILING ADDRESS: G3 c, s5'g.f/ -V
OWNER PROPERTY ADDRESS: 29 AA I-
OWNER TELEPHONE NUMBER: - S j f r-F
TAX MAP NO. : Section S-5- Block (0 Lot 3
CROSS STREET: „u R zz=a L- Q_
TYPE OF SYSTEM: Septic Tank V**� New Existing
Cesspool ✓ New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: t( — 30
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.)
Signatu o Applicant
RECEIVED BY:
To CI rk's Off ce
DAT E: 4�z�z-
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