HomeMy WebLinkAboutKrupski (2) y° Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY ®� TELEPHONE
TOWN CLERK (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. 867-R Residential X Non-Residential
Fee $ 10. 00 Septic Cesspool X
New Existing X
Name Of Owner KRUPSKI, ANTHONY
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Mailing Address 1 MILL LANE
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Mailing Address 2
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City St Zip MATTITUCK NY 11952-0000
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Property Address 1 MILL LANE
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Property Address 2
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City St Zip MATTITUCK NY 11952-0000
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Owner Telephone No. 516-298-8517
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Tax Map No. section 107. 00 block 10 lot 9. 000
Cross Street WICKHAM AVENUE
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Date Of Last Pump Out 0/00/72
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Issue Date: 9/28/88 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK c�vFFD(,�
Town of Southold 0�� CSG Application No.
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road o -� 7 Residential
P. 0. Box 1179 to 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
OWNER NAME: A IV jO
OWNER MAILING ADDRESS: f fo -
C
OWNER PROPERTY ADDRESS:
H/ lr
OWNER TELEPHONE NUMBER: r -1 -7
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TAX MAP NO. : Section /0 7 Block /() —Lot—?
CROSS STREET: jl _
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:�SEP
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.)
Signatures of Appliggnt
RECEIVED BY: c, _Q
F _EIVEown Clerk's Offi e
DAT E: , 4! { -
; -
RECOVED
1u01 Viler
s' r4 `3
lo%rn Clerk Southold
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