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OFFICE OF THE TOWN CLERK JFO �
Town of Southold
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. 0. Box 1179
Southold, New York 11971 ® �-
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Telephone
(516) 765-1801
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TOWN OF SOUTHOLD
i
SOUTHOLD WASTEWATER DISPOSAL' DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 220 Residential X
Fee $ 10.00 Non-Residential
Septic Cesspool X
NAME OF OWNER:-- Antone Kr-upski
OWNER MAILING ADDRESS: South Harhnr Road
Southold Npw York 11471-
OWNER PROPERTY ADDRESS: South Harbor Road
Southold New YOrk
OWNER TELEPHONE NUMBER:. 516-765-3352
TAX MAP NO. : , Section 87 Block 1 Lot 0
CROSS STREET: Laughing Waters
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Fall of 1985
Judith T. Terry
Southold Town Clerk
DATE: February 11, 1987
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold 0��� �C�� Application No. as
Judith T. Terry, Town Clerk �►
Town Hall, 53095 Main Road -� 7 Residential
P. 0. Box 1179 U' Non-Residential-
Southold, New York 11,971 O
Telephone.( Y►��
(516) 765-1801
'"TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE f/d /S7
7
OWNER NAME: 11a�
OWNER MAILING ADDRESS: SO u % ,�� ,� 4-d-p-_D� ?
a c.� 44oG .DAY
OWNER PROPERTY ADDRESS: T# G yf? R o A D-
OWNER TELEPHONE NUMBER: 4 3--
TAX MAP NO. : Section 7 Block ) Lot
CROSS STREET: CC.ce,
TYPE OF SYSTEM: Septic Tank G-"' New Existing
C�
Cesspool NewV___/ Existing
Residential r/ Non-Residential
DATE OF PREVIOUS PUMP-OUT: r , If 1147, /
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: c�c<_(�
RK-MV,6wn Jerk's Office
DATE:
town 0l .k Southold
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