HomeMy WebLinkAboutKrupski (5) Town Hall, 53095 Main Road,
�® ®� P.O. Box 1179
Southold, New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(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. 1348-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner KRUPSKI, STANLEY W.
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Mailing Address 1 RR 2, 26155 ROUTE 48
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Mailing Address 2
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City St Zip CUTCHOGUE NY 11935-0000
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Property Address 1 26155 ROUTE 48
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Property Address 2
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City St Zip CUTCHOGUE NY 11935-0000
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Owner Telephone No. 516-734-6922
Tax Map No. section 84.00 block 2 lot 3.000
Cross Street BRIDGE LANE
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Date Of Last Pump Out 0/00/00
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Issue Date: 12/19/89 Judith T. Terry
-------- Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK
Town of Southold O��c��F� D�C��/ Application No. /3yk`l
Judith T. Terry, Town Clerk y
Town Hall, 53095 Main Road -< $10.00 - Residential
P. 0. Box 1179 Ln $25.00 - Non-Residential
Southold, New York 11971 O
Telephone( �.ao
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $
DATE /Alo
OWNER NAME:_ S T,4 Yk P S /� I
OWNER MAILING ADDRESS:
OWNER DPCPE TV A DDES
OWNER TELEPHONE NUMBER:
TAX MAP NO. : Section g 4 Block Lot
CROSS STREET: icl ANV--
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential ✓1 Non-Residential
DATE OF PREVIOUS PUMP-OUT: / / / -lS 1 ��
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.)
S' nature o pp cant
RECEIVED BY:
Town Clerk's Office
DATE:
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