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
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Mailing Address 1 P. O. BOX 1772
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Mailing Address 2
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vCity St Zip SOUTHOLD NY 11971-0000
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Property Address 1 200 GRISSOM ROAD
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Property Address 2
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City St Zip SOUTHOLD NY 11971-0000
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Owner Telephone No. 516-765-5618
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Tax Map No. section 78.00 block 1 lot 10.005
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Cross Street SLEEPY HOLLOW LANE
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Date Of Last Pump Out 0/00/00
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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
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OWNER PROPERTY ADDRESS: ('
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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.)
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Signature of Opplicant
RECEIVED BY: ,l�J
own (Clerk's Office
DATE:
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