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HomeMy WebLinkAboutKrupski (4) „ Town Hall, 53095 Main Road -u . P.O. Box 1179 ® ®° Southold, New York 119 71 JUDITH T.TERRY ®� TELEPHONE TOWN CLERK (516) 765-1801 REGISTRAR Ol-VITAL STATISTICS OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD SOUTHOLD WASTEWATER DISPOSAL PERMIT OPERATION PERMIT SEPTIC TANK or CESSPOOL Operation Permit No. 924-R Residential X Non-Residential Fee $ 10.00 Septic Cesspool X New X Existing Name Of Owner KRUPSKI, RAYMOND AND CECELIA ------------------------------ Mailing Address 1 P. O. BOX 1772 ------------------------------ Mailing Address 2 ------------------------------ vCity St Zip SOUTHOLD NY 11971-0000 -------------------- -- ---------- Property Address 1 200 GRISSOM ROAD ------------------------------ Property Address 2 ------------------------------ City St Zip SOUTHOLD NY 11971-0000 -------------------- -- ---------- Owner Telephone No. 516-765-5618 ------------ Tax Map No. section 78.00 block 1 lot 10.005 ------ --- ------ Cross Street SLEEPY HOLLOW LANE ------------------------------ Date Of Last Pump Out 0/00/00 ---------------------------------- Issue Date: 11/21/88 Judith T. Terry -------- Southold Town Clerk (TOWN SEAL) OFFICE OF THE TOWN CLERK Town of Southold ��� �QG Application No. Judith T. Terry, Town Clerk y Town Hall, 53095 Main Road o -� Residential P. 0. Box 1179 cn 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:( MQM t- C.Q0210, `fWr )as V\% OWNER MAILING ADDRESS: Fa Sc� U c9V OWNER PROPERTY ADDRESS: (' U�\d NL1 OWNER TELEPHONE NUMBER: ::j_(65 5(01 TAX MAP NO. : Section 0—] Block ` Lot CROSS STREET:NPM & Ow�wy TYPE OF SYSTEM: Septic Tank New Existing Cesspool New Existing Residential Non-Residential DATE OF PREVIOUS PUMP-OUT: 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.) • k, O� Signature of Opplicant RECEIVED BY: ,l�J own (Clerk's Office DATE: 'r. .s -_> y ^ f � C`^�n.��.� S� h �� �� b - - - - .. �', 1 , � �� ��' �� . � � ��- � � _ ,� _ �,�.