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ELIZABETH A.NEVILLE �t�� #� Town Hall, 53095 Main Road
TOWN CLERK t P.O. Box 1179
tgo Southold,New York 11971
REGISTRAR OF VITAL STATISTICS O /�� Fax (516) 765-1823
MARRIAGE OFFICER ®�'�� Telephone (516) 765-1800
RECORDS MANAGEMENT OFFICER : 4�� ,ss22,,, �'
FREEDOM OF INFORMATION OFFICER `zs'
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT'
SEPTIC TANK or CESSPOOL
Operation Permit No. 3767-R Residential X Non-Residential
Fee $ 10.00 New Existing X
Name Of Owner KRUSZESKI, ROBERTA
Mailing Address 1 305 LANDING LANE
Mailing Address 2
City St Zip GREENPORT NY 11944-0000
Property Address 1 305 LANDING LANE
Property Address 2 -
City St Zip GREENPORT NY 11944-0000
Owner Telephone No. 516-477-1766
Tax Map No. section 43.00 block 4 lot 14.000
Cross Street MANHASSET AVENUE
Issue Date: 2/23/98 Elizabeth A. Neville
Southold Town Clerk _
(TOWN SEAL)
OFFICE OF THE TOWN CLERK OCOMA'
TOWN OF SOUTHOLD ff "x •.4COlt,:,41,\ Application No. 3 " /
ELIZABETH A.NEVILLE,TOWN CLERK ' 1,...,:-.1.!,: 4 s 1 y
�C 1 $10 .00 - Residential i..__-----/- P.O.BOX 1179 ,3,f : ,`, �1 $25.00 - Non-Residential
SOUTHOLD,NEW YORK 11971 v. � ��`
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Telephone.( 't, to
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICAT ION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /c' i O O
•
DATE . 7f c19
OWNER NAME: /6hio.e>4g //,__/./S7_ps/[ ;
OWNER MAILING ADDRESS: C'J 7rQ/y�� Lne
ire11124l?.7L , 74y 1/ q
OWNER PROPERTY ADDRESS: .SQ`y/e
OWNER TELEPHONE NUMBER: \7/6 - /1 7 7 /7 , (
y TAX MAP NO. : Section rl 8 Block IA Lot , IA
CROSS STREET: C/dS 27 / ,
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing V.
Residential Non-Residential
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, apprimately, to builkig and closest road.)
A. Io! . 1..e ..e./..t .
' t igna'T'e of Ap lig ant
s
RECEIVED BY: •
Town Clerk's Office
DATE:
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